A retrospective study on the incidence and risk factors of severe hypoglycemia in primary care

Screening for Hypoglycaemia Risk and Medication Changes in Diabetes Patients Using Pharmacy Dispensing Data

Background: To improve hypoglycaemia management in primary care, more insight is needed into the opportunities to screen for hypoglycaemia risk and subsequent treatment modification using routinely available data. Our primary aim was to assess the number of diabetes patients with an estimated high risk of hypoglycaemia and describe the treatment changes in these patients using pharmacy dispensing data. Additionally, our aim was to investigate patient characteristics associated with such treatment changes. Methods: A drug utilisation cohort study with a 1-year follow-up using the IADB.nl pharmacy database was conducted. Patients aged 35 years or older who received at least two glucose-lowering medication dispensings in 2019 were included. Hypoglycaemia risk was determined using a validated algorithm based on patient demographics and dispensing data. The hypoglycaemia risk score ranged between 0 and 1. The anniversary method was used to evaluate treatment changes after 1 year. Factors associated with treatment changes were assessed by multinomial logistic regression. Results: Around one-quarter (26.9%) of the 36,628 included patients had a hypoglycaemia score of 0.6 or more. After a 1-year follow-up, the majority of these patients (88.9%) experienced no diabetes treatment changes. De-intensification was observed for 8.8% and intensification for 2.3%. Having a high-risk score, being female, and being younger in age were associated with de-intensification. Conclusions: A substantial number of primary care patients using glucose-lowering medications appear at risk of hypoglycaemia, whereas few of them undergo medication de-intensification. Pharmacy dispensing data can be helpful in screening for diabetes patients in whom a review of treatment is indicated.

Economic Burden of Severe Hypoglycemia Among Patients With Diabetes Mellitus

BACKGROUND

Bangladesh is anticipated to have the eighth-highest number of diabetic patients within the next 15 years. Approximately one-fifth of adult diabetes patients reside in Southeast Asian nations. This study aimed to find out the economic burden of extreme hypoglycemia on diabetic sufferers in Bangladesh.

METHODS

A cross-sectional study was carried out amongst 164 Type 2 Diabetes sufferers admitted due to extreme hypoglycemia within 15 months at BIRDEM in Dhaka to decide if they have the impact of extreme hypoglycemia on the cost of illness. The cost was once expressed in BDT.

RESULTS

Direct medical cost (37058) and direct non-medical cost (5261) was estimated during the study. Among the direct medical cost, hospital cost was 17735, physician cost was 5745, nonmedical transport cost was 1802, and attendant cost was 3459. The total cost was 48743 BDT (€617) for each severe hypoglycemic event leading to hospitalization, and 6.4244 BDT (€82.4) would be the indirect cost of reduced productivity from spending 5.8 days (46.4 hours) in the hospital.

CONCLUSION

The analysis indicates that hypoglycemia has a significant negative influence on the cost and reduces the work output of diabetics.

Impediments to and impact of checklists on performance of emergency interventions in primary care: an in situ simulation-based randomized controlled trial

OBJECTIVE

Medical crises occur rather seldom in the primary care setting, but when they do, initial management impacts on morbidity and mortality. Factors that impede the performance of emergency interventions in primary care have not been studied through in-situ simulation. Checklists reportedly improve crisis management.

DESIGN

This randomized controlled trial evaluated emergency intervention performance during two scenarios (hypoglycemia-coma and anaphylaxis-cardiac arrest) simulated at primary care centers, and whether checklist access improved performance.

SETTING

Twenty-two primary care centers in Southern Sweden participated in the study.

SUBJECTS

A total of 347 personnel performed 100 simulations, 45 with and 55 without checklist access.

MAIN OUTCOME MEASURES

Time and impediments to performance of five emergency interventions in each scenario.

RESULTS

On 28 of the 37 occasions when the adrenalin auto-injector was employed, the administration technique was incorrect. In 9 of 49 scenarios, teams had trouble locating the 30% glucose solution. Median time to supplemental oxygen administration during the first scenario was 186 s compared with 96 s during the second scenario (p < 0.001). Checklist access had no significant impact on time to performance of emergency interventions, aside from shorter time to adequate glucose or glucagon administration (median times 632 s with, 756 s without checklist access; p = 0.03).

CONCLUSION

Unfamiliarity with local emergency equipment impedes the performance of emergency interventions during crises simulated in the primary care setting. Simply providing checklist access does not improve the performance of emergency interventions.KEY POINTSLittle is known about the factors that affect the performance of emergency interventions in the primary care setting.Unfamiliarity with local emergency equipment impedes the performance of emergency interventions during crises simulated in the primary care setting.Simply providing crisis checklist access does not improve the performance of emergency interventions in the primary care setting.

Incidence and prevalence of hypoglycaemia in type 1 and type 2 diabetes individuals: A systematic review and meta-analysis

BACKGROUND

Previous meta-analysis investigating the incidence and prevalence of hypoglycaemia in both types of diabetes is limited. The purpose of this review is to conduct a systematic review and meta-analysis of the existing literature which investigates the incidence and prevalence of hypoglycaemia in individuals with diabetes.

METHODS

PubMed, Embase and Cochrane library databases were searched up to October 2018. Observational studies including individuals with diabetes of all ages and reporting incidence and/or prevalence of hypoglycaemia were included. Two reviewers independently screened articles, extracted data and assessed the quality of included studies. Meta-analysis was performed using a random effects model with 95% confidence interval (CI) to estimate the pooled incidence and prevalence of hypoglycaemia in individuals with diabetes.

RESULTS

Our search strategy generated 35,007 articles, of which 72 studies matched the inclusion criteria and were included in the meta-analysis. The prevalence of hypoglycaemia ranged from 0.074% to 73.0%, comprising a total of 2,462,810 individuals with diabetes. The incidence rate of hypoglycaemia ranged from 0.072 to 42,890 episodes per 1,000 person-years: stratified by type of diabetes, it ranged from 14.5 to 42,890 episodes per 1,000 person-years and from 0.072 to 16,360 episodes per 1,000-person years in type 1 and type 2 diabetes, respectively.

CONCLUSION

Hypoglycaemia is very common among individuals with diabetes. Further studies are needed to investigate hypoglycaemia-associated risk factors.

Incidence and Risk Factors Associated with Outpatient Hypoglycemia in Patients with Type 2 Diabetes and Chronic Kidney Disease: A Nationwide Study

BACKGROUND

Chronic kidney disease and hypoglycemia are common complications in individuals with diabetes. Currently, the association of renal function with hypoglycemic complications in type 2 diabetes mellitus (T2DM) is inconclusive. This study aims to assess the associations between estimated glomerular filtration rate (eGFR) and cumulative incidence of hypoglycemia, hypoglycemia-related hospitalizations, and incidence of outpatient hypoglycemia among T2DM patients in Thailand using a nationwide patient sample.

METHODS

We conducted a nationwide retrospective cohort study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study assessed adult T2DM patients from 831 public hospitals in Thailand in the year 2012-2013. eGFR was categorized into ≥90, 60-89, 30-59, 15-29, and <15 mL/min/1.73 m². The associations between eGFR and hypoglycemia, hypoglycemia-related hospitalizations, and incidence of outpatient hypoglycemia were assessed using multivariate logistic regression and Poisson regression.

RESULTS

A total of 25,056 T2DM patients with available eGFR were included in the analysis. The mean age was 60.9 ± 10.5 years. The cumulative incidence of hypoglycemia and hypoglycemia-related hospitalizations was 3.6% and 1.7%, respectively. Incidence of outpatient hypoglycemia, mild hypoglycemia, and severe hypoglycemia was 2.99 (2.59-3.43), 2.47 (2.11-2.88), and 0.52 (0.36-0.72) per 100 patient-years, respectively. Patients with eGFR of 30-59, 15-29, and <15 mL/min/1.73 m² were significantly associated with an increased risk of hypoglycemia, hypoglycemia-related hospitalizations, and incidence of outpatient hypoglycemia when compared to patients with eGFR of ≥90 mL/min/1.73 m².

CONCLUSION

Reduced eGFR was independently associated with increased hypoglycemia, hypoglycemia-related hospitalizations, and risk of outpatient hypoglycemia. Increasing awareness of the heightened risk of hypoglycemia with declining renal function may prompt changes to diabetic management for at-risk individuals.

Predictive modeling of hypoglycemia for clinical decision support in evaluating outpatients with diabetes mellitus

Objective: Hypoglycemia occurs in 20-60% of patients with diabetes mellitus. Identifying at-risk patients can facilitate interventions to lower risk. We sought to develop a hypoglycemia prediction model. Methods: In this retrospective cohort study, urban adults prescribed a diabetes drug between 2004 and 2013 were identified. Demographic and clinical data were extracted from an electronic medical record (EMR). Laboratory tests, diagnostic codes and natural language processing (NLP) identified hypoglycemia. We compared multiple logistic regression, classification and regression trees (CART), and random forest. Models were evaluated on an independent test set or through cross-validation. Results: The 38,780 patients had mean age 57 years; 56% were female, 40% African-American and 39% uninsured. Hypoglycemia occurred in 8128 (539 identified only by NLP). In logistic regression, factors positively associated with hypoglycemia included infection, non-long-acting insulin, dementia and recent hypoglycemia. Negatively associated factors included long-acting insulin plus sulfonylurea, and age 75 or older. The models' area under curve was similar (logistic regression, 89%; CART, 88%; random forest, 90%, with ten-fold cross-validation). Conclusions: NLP improved identification of hypoglycemia. Non-long-acting insulin was an important risk factor. Decreased risk with age may reflect treatment or diminished awareness of hypoglycemia. More complex models did not improve prediction.

Risk of all-cause and CHD mortality in women versus men with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

Previous studies have shown sex-specific differences in all-cause and CHD mortality in type 2 diabetes. We performed a systematic review and meta-analysis to provide a global picture of the estimated influence of type 2 diabetes on the risk of all-cause and CHD mortality in women vs men.

METHODS

We systematically searched PubMed, EMBASE and Web of Science for studies published from their starting dates to Aug 7, 2018. The sex-specific hazard ratios (HRs) and their pooled ratio (women vs men) of all-cause and CHD mortality associated with type 2 diabetes were obtained through an inverse variance-weighted random-effects meta-analysis. Subgroup analyses were used to explore the potential sources of heterogeneity.

RESULTS

The 35 analyzed prospective cohort studies included 2 314 292 individuals, among whom 254 038 all-cause deaths occurred. The pooled women vs men ratio of the HRs for all-cause and CHD mortality were 1.17 (95% CI: 1.12-1.23, I2 = 81.6%) and 1.97 (95% CI: 1.49-2.61, I2 = 86.4%), respectively. The pooled estimate of the HR for all-cause mortality was approximately 1.30 in articles in which the duration of follow-up was longer than 10 years and 1.10 in articles in which the duration of follow-up was less than 10 years. The pooled HRs for all-cause mortality in patients with type 2 diabetes was 2.33 (95% CI: 2.02-2.69) in women and 1.91 (95% CI: 1.72-2.12) in men, compared with their healthy counterparts.

CONCLUSIONS

The effect of diabetes on all-cause and CHD mortality is approximately 17 and 97% greater, respectively, for women than for men.

Reporting Severe Hypoglycemia in Type 1 Diabetes: Facts and Pitfalls

PURPOSE OF REVIEW

To describe potential factors influencing reporting of severe hypoglycemia in adult patients with type 1 diabetes and to analyze their effect on reported rates of severe hypoglycemia.

RECENT FINDINGS

Reported rates of severe hypoglycemia defined as need for third party assistance vary between 0.3-3.0 events per patient-year in unselected cohorts, corresponding to a yearly prevalence range of 10-53%. When defined as need for parenteral therapy with glucose or glucagon or need for admission to an emergency unit or hospitalization, incidence and prevalence rates of severe hypoglycemia are 0.02-0.5 events per patient-year and 1-29%, respectively. When subjects with recurrent severe hypoglycemia in the past or suffering from impaired hypoglycemia awareness are excluded from participation in studies, lower rates are reported. Studies applying anonymous reporting or reporting by partners report higher rates of severe hypoglycemia. There is a large variation between studies reporting incidence and prevalence of severe hypoglycemia in patients with type 1 diabetes, mainly explained by definition of severity, methods of reporting, and patient selection. These findings call for consensus about hypoglycemia definition and reporting in future research.

Increase in the incidence of severe hypoglycaemia in people with Type 2 diabetes in spite of new drugs: analysis based on health insurance data from Germany

AIM

To evaluate the use of new anti-hyperglycaemic agents that offer effective glycaemic control while reducing risk of hypoglycaemia, by analysing the incidence rates of severe hypoglycaemia in 2006 vs 2011 in relation to the medication.

METHODS

This cross-sectional, population-based study used German health insurance data. All adults diagnosed with Type 2 diabetes mellitus (extrapolated to the German population: 6.35 million in 2006 and 7.52 million in 2011) were screened for severe hypoglycaemia. Anti-hyperglycaemic agents were identified by their Anatomical Therapeutic Chemical code, and defined daily doses of each medication were calculated.

RESULTS

The severe hypoglycaemic event rate was 460 per 100,000 people/year in 2006 and 490 per 100,000 people/year in 2011. In 2006 and 2011, 10.9% and 7.3%, respectively, of all people with severe hypoglycaemia were on sulfonylureas, while 12.7% and 9.3%, respectively, were on a combination therapy of metformin and sulfonylureas. Among those with severe hypoglycaemia, there were no prescriptions of dipeptidyl peptidase-4 inhibitors or glucagon-like peptide-1 receptor agonists in 2006, but in 2011, 1.55% and 0.17%, of those with severe hypoglycaemia were receiving the respective treatments. In 2006 vs 2011, human insulin was prescribed for 11.3% vs 10.3% of people with severe hypoglycaemia, while insulin analogues were prescribed for 5.4% vs 8.1%, and mixed human insulins for 19.7% vs 14.0% of patients with severe hypoglycaemia. People receiving insulin analogue therapy had a higher risk of severe hypoglycaemia than those receiving metformin, after adjusting for age, gender, nephropathy diagnosis and year of survey (odds ratio 14.6; CI 13.3-15.9).

CONCLUSION

The incidence of severe hypoglycaemic events in Germany increased between 2006 and 2011, despite increased use of newer anti-hyperglycaemic agents and decreased use of insulins.

Incidence Trends and Predictors of Hospitalization for Hypoglycemia in 17,230 Adult Patients With Type 1 Diabetes: A Danish Register Linkage Cohort Study

OBJECTIVE

This study aimed to examine nationwide incidence trends and predictors of hospitalization for hypoglycemia (HH) in the adult population with type 1 diabetes in Denmark.

RESEARCH DESIGN AND METHODS

All 17,230 patients with type 1 diabetes aged 16 years and above registered in the Danish Adult Diabetes Database (DADD) from 2006 were followed to 2012 by linkage of registers. Incidence rates of HH were modeled by Poisson regression by calendar time, taking sex, age, diabetes duration, clinical variables, and previous HH into account.

RESULTS

A total of 2,369 events of HH occurred among 1,735 patients with type 1 diabetes of HH during 70,002 patient-years (mean follow-up 3.7 years). A decrease in incidence rate was observed with calendar time with an 8.4% (4.9-11.7%) annual decrease. Predictors of HH included previous HH, age, diabetes duration, albuminuria, and HbA_1c.

CONCLUSIONS

This study revealed a decreasing trend in incidence of HH in patients with type 1 diabetes. Previous HH, longer diabetes duration, macroalbuminuria, and HbA_1c were associated with increased risk of HH in type 1 diabetes, and attention to those factors is warranted in both clinical and public health aspects.

Impact of patient and treatment characteristics on glycemic control and hypoglycemia in patients with type 2 diabetes initiated to insulin glargine or NPH: A post hoc, pooled, patient-level analysis of 6 randomized controlled trials

BACKGROUND

The goal of this post hoc analysis was to determine key patient and treatment-related factors impacting glycosylated hemoglobin (A1C) and hypoglycemia in patients with uncontrolled type 2 diabetes who were initiated to basal insulin (neutral protamine Hagedorn [NPH] or glargine).

METHODS

Using individual patient-level data pooled from 6 treat-to-target trials, 2600 patients with type 2 diabetes on oral antidiabetic agents initiated to insulin glargine or NPH and treated for 24 to 36 weeks were analyzed.

RESULTS

Both treatments led to significant reduction in A1C levels compared with baseline, with no differences between treatment groups (mean ± standard deviation; glargine: -1.32 ± 1.2% vs NPH: -1.26 ± 1.2%; P = 0.15), with greater reduction in the BMI ≥30 kg/m group than in the BMI <30 kg/m group. Glargine reduced A1C significantly more than NPH in the BMI <30 kg/m group (-1.30 ± 1.18% vs -1.14 ± 1.22, respectively; P = 0.008), but not in the BMI ≥ 30 kg/m group (-1.37 ± 1.19 vs -1.48 ± 1.22, respectively; P = 0.18). Similar proportions of patients achieved A1C target of <7% (glargine 30.6%, NPH 29.1%; P = 0.39). Incidence of severe and severe nocturnal hypoglycemia was significantly lower in glargine versus NPH-treated patients (2.0% vs 3.9%; P = 0.04, and 0.7% vs 2.1%; P = 0.002, respectively), and occurred primarily in the BMI <30 kg/m group.

CONCLUSIONS

Initiation of basal insulin is highly effective in lowering A1C after oral antidiabetic agent failure. Glargine decreases A1C more than NPH in nonobese patients, and reduces the risk for severe and severe nocturnal hypoglycemia versus NPH both in obese and nonobese patients, but more so in nonobese patients. Thus, it is the nonobese patients who may benefit more from initiation of basal insulin as glargine than NPH.

Metabolic control and hypoglycaemia in people with type 2 diabetes on conventional or intensified insulin therapy: a 22 year retrospective single centre survey

BACKGROUND

Multiple insulin injection therapy can easily be adapted to the patient's needs. Therefore, it is supposed that more intensive insulin therapy is associated with better metabolic control and less hypoglycaemia compared with a conventional insulin strategy in patients with type 2 diabetes.

METHODS

HbA1c and incidence of non-severe and severe hypoglycaemia were analysed with regard to the strategy of insulin therapy [multiple insulin injection therapy with preprandial insulin with or without basal insulin or conventional insulin therapy with twice-daily premix insulin] from 20 943 visits of 1417 people treated with insulin with type 2 diabetes in a university outpatient department for endocrinology and metabolic diseases over a period of 22 years.

RESULTS

Multiple insulin injection therapy was used in 13 896 (66.4%) of all 20 942 visits. Compared with conventional insulin therapy, these patients were younger (62.0 vs 68.7 years; p < 0.001), had a slightly longer diabetes duration (16.5 vs 15.8 years; p < 0.001) and higher body mass index (32.8 vs 30.9 kg/m(2) ; p < 0.001), a higher insulin dose (76.4 vs 46.5 IU/day; p < 0.001), more frequent blood glucose monitorings/week (24.2 vs 14.8; p < 0.001), a slightly lower HbA1c [7.7 (61.2) vs 7.9% (62.9 mmol/mol); p < 0.001] but more non-severe hypoglycaemic incidences per week (0.3 vs 0.2; p = 0.01). Episodes of severe hypoglycaemia were rare and comparable (0.01/patient/year) with both insulin therapy strategies.

CONCLUSIONS

Multiple insulin injection therapy and conventional insulin therapy yielded comparable metabolic control with HbA1c below 8% (63.9 mmol/mol), but multiple insulin injection therapy is associated with higher body mass index and higher incidence of non-severe hypoglycaemia. Copyright © 2016 John Wiley & Sons, Ltd.

Incidence and risk factors of hypoglycemia among Type 2 diabetic patients in a South Indian hospital

AIM

The study was aimed at assessing the cumulative incidence of hypoglycemia and precipitating risk factors among type 2 diabetes mellitus in-patients of a tertiary care hospital in South India.

METHODS

The prospective cross sectional study spanning 14 months was conducted in a tertiary care hospital in Kerala. All T2DM patients who were administered any form of insulin during the length of hospital stay was monitored for assessing the hypoglycemic episodes. Any patient with a GRBS value less than 70mg/dL was defined to be hypoglycemic as per the ADA guidelines. The statistical analysis of collected data was performed using SPSS 18 for windows version.

RESULTS

Of the 1650 subjects enrolled in the study, 204 subjects developed hypoglycemia. The sample composed of 60.8% females and 39.2% males and the difference was significant with p=0.02. A significant positive correlation was observed between HbA1c values and GRBS value, with a 2 tailed Pearson correlation coefficient of 0.027. On stratifying as per the modality of insulin dose prescribed, 72.5% of the hypoglycemic patients were found to have been administered fixed dose insulin.

CONCLUSION

The cumulative incidence of institutional hypoglycemia among type 2 diabetic inpatients was gauged as 12.36%; among which, 26.96% had asymptomatic episodes.

Postprandial self-monitoring of urine glucose reflects glycaemic control in people with relatively well controlled Type 2 diabetes mellitus not treated with insulin: a retrospective cohort study

AIM

To analyse the association of self-monitoring of urine glucose with HbA1c concentration in people with Type 2 diabetes not treated with insulin.

METHODS

We studied the association of postprandial self-monitored urine glucose with HbA1c concentrations in 264 people with Type 2 diabetes (mean age 62.4 years, time since diagnosis of diabetes 6.8 years and HbA1c 50 mmol/l). All patients took part in a diabetes treatment and teaching programme. HbA1c values were adjusted according to the Diabetes Control and Complication Trial.

RESULTS

The mean ( ± sd) HbA1c concentration for the patients with constant negative urine glucose tests (56.1% of patients) was 46 ( ± 6) mmol/mol [6.4 ( ± 0.6)%]. This was significantly lower than in patients with < 50% positive urine glucose tests (33.3% of patients): mean ( ± sd) HbA1c was 53 ( ± 8) mmol/mol [7.0( ± 0.7)%] and also lower than in patients with ≥50% positive tests (10.6% of patients): mean ( ± sd) HbA1c of 57 ( ± 8) mmol/mol [7.4 ( ± 0.7)%]; P < 0.001. There was a significant correlation between the urine glucose test results and HbA1c (r = 0.416; P < 0.001).

CONCLUSION

HbA1c concentrations were observed to be in the near-normal range for people with Type 2 diabetes not receiving insulin treatment who were negative for postprandial glucosuria. Urine glucose self-monitoring is a cheap and effective method to determine the quality of glucose control.

Gender-based differences in glycaemic control and hypoglycaemia prevalence in patients with type 2 diabetes: results from patient-level pooled data of six randomized controlled trials

AIMS

To determine the impact of gender on glycaemic control and hypoglycaemia in insulin-naïve patients with type 2 diabetes (T2DM).

METHODS

Data were pooled from six randomized clinical trials of insulin glargine or NPH insulin in insulin-naïve, inadequately controlled patients. Female [n = 1251; mean glycated haemoglobin (HbA1c) level 8.99%, age 56.91 years, diabetes duration 9.84 years] and male patients (n = 1349; mean HbA1c 8.9%, age 57.47 years, diabetes duration 10.13 years) were started on and treated with insulin glargine or NPH insulin for 24-36 weeks. HbA1c and fasting blood glucose levels, percent achieving HbA1c target of <7% and insulin dose change were recorded.

RESULTS

For both men and women, HbA1c levels were significantly reduced over time (p < 0.001); a significantly greater HbA1c reduction was observed in men than in women (-1.36 vs. -1.22; p = 0.002). Significantly fewer women achieved target HbA1c of <7% (p < 0.001). At the study end, women had a significantly higher insulin dose/kg than men (0.47 vs. 0.42 U/kg; p < 0.001). The incidence rates of severe and severe nocturnal hypoglycaemia were significantly higher in women (3.28% vs. 1.85%; p < 0.05 and 2.24% vs. 0.59%; p < 0.001, respectively). Women were more likely to experience severe hypoglycaemia [odds ratio (OR) 1.80; 95% confidence interval (CI) 1.08, 3.00; p = 0.02] and severe nocturnal hypoglycaemia (OR: 3.80; 95% CI 1.72, 8.42; p = 0.001).

CONCLUSIONS

These observations confirm studies that found a smaller improvement in HbA1c and greater hypoglycaemia in women during insulin treatment. Physicians should be aware of the need to determine and closely monitor dosing, particularly in women, to optimize the balance between glycaemic control and hypoglycaemia risk.

Efficacy and safety of sitagliptin in Japanese patients with type 2 diabetes

BACKGROUND

The aim of this study was to investigate the clinical efficacy and safety of sitagliptin in Japanese patients with type 2 diabetes.

METHODS

A total of 3,247 subjects treated with sitagliptin were retrospectively recruited. Glucose parameters were collected at baseline, and 1, 3 and 6 months after initiation of sitagliptin. In addition, we explored factors that can be used to predict sitagliptin-induced reduction in HbA1c using linear mixed effect model. Factors associated with hypoglycemic events were examined by logistic analyses.

RESULTS

We analyzed the available data of 3,201 subjects (1,287 females). Treatment of sitagliptin significantly reduced HbA1c level from 7.44±1.20% at baseline to 6.73±0.99% at 6 months (P < 0.0001). Linear mixed effect model analyses demonstrated that reduction of HbA1c was associated with higher baseline HbA1c level, younger age, lower BMI and sitagliptin monotherapy. During this study, 82 cases of hypoglycemia were recorded. Logistic analyses indicated that hypoglycemic events were more frequent in female patients, and patients with low BMI, long history of type 2 diabetes, high HbA1c and on combination therapy experienced. Other adverse events were rare and mild.

CONCLUSIONS

Sitagliptin is effective for diabetic management and generally well tolerated in Japanese patients with type 2 diabetes. This trial was registered with UMIN (no. 000004121).

Dynamic risk factors associated with non-severe hypoglycemia in patients treated with insulin glargine or exenatide once weekly

BACKGROUND

Glycemic control in patients with type 2 diabetes is a dynamic process, and changes in risk factors affecting the incidence of hypoglycemia are not well understood. This study explored the association of longitudinal interactive effects of clinical risk factors and concomitant medications on hypoglycemia risk in patients treated with insulin glargine (IG) or exenatide once weekly (EQW).

METHODS

Pooled patient-level 52-week longitudinal data of treatment with EQW (n = 541) or IG (n = 223) from three controlled trials were analyzed.

RESULTS

Proportions of patients with at least one episode of hypoglycemia in the EQW and IG groups were 23% and 54%, respectively. Compared with patients with HbA1c ≥7% (53 mmol/mol) over time, patients with HbA1c <7% had significantly higher hypoglycemia risk in both groups (95% confidence intervals [CI] of odds ratios [OR]: EQW-1.21, 2.81; IG- 6.26, 9.84). The patterns of interaction effect of changing body mass index (BMI) and HbA1c on hypoglycemia risk differed in the two treatment groups: patients with with BMI >35 kg/m(2) had a 119% increased hypoglycemia risk in the EQW group, but a 57% reduced risk in the IG group. Sulfonylurea-treated patients in the EQW and IG groups had 4.7- and 3-fold additional hypoglycemia risk, respectively, versus non-sulfonylurea-treated patients.

CONCLUSION

This study revealed differential effects of tight glycemic control and itsinteraction with treatment-induced changes in BMI on hypoglycemia risk its interaction in patients treated with EQW and IG. The residual adverse effect of sulfonylurea was higher in EQW-treated patients.

Hypoglycaemia requiring medical assistance in patients with diabetes: a prospective multicentre survey in tertiary hospitals

AIM

Hypoglycaemia is considered a factor contributing to morbidity and mortality in patients with diabetes. The aim of the present study was to examine the frequency, clinical characteristics, predisposing factors and outcomes of iatrogenic hypoglycaemia requiring medical assistance.

METHODS

Eight hospitals participated in this prospective survey of documented iatrogenic hypoglycaemia at their emergency departments. Cases with type 2 diabetes (T2D) were compared with a control group, consisting of patients visiting the outpatients' diabetes clinics of the same hospitals during the same time period.

RESULTS

Median survey duration was 16.5 months, and 295 episodes of iatrogenic hypoglycaemia were recorded. Frequency varied across centres from 0.25 to 0.78 cases per 100 presenting patients. Most cases (90.8%) were observed in patients with T2D (mean age: 76.7±10.1 years), while 8.1% of events were recorded in patients with type 1 diabetes (mean age: 42.7±18.3 years). Total in-hospital mortality was 3.4%, and all involved patients with T2D. In T2D patients, advanced age (OR: 1.3 [1.20-1.45] for 5-year increase), use of sulphonylureas (OR: 4.0 [2.5-6.36]), use of insulin (OR: 2.35 [1.42-3.95]), lower estimated GFR (OR: 1.15 [1.07-1.23] at 10mL/min) and number of comorbidities (OR: 1.74 [1.34-2.27]) were each independently associated with hypoglycaemia requiring medical assistance.

CONCLUSION

Hypoglycaemia requiring medical assistance in patients with diabetes is a moderately common condition seen in emergency departments and has a mortality rate of 3.4%. The majority of cases involve elderly individuals with T2D who are suffering from serious comorbidities and treated with insulin and/or sulphonylureas.

Relational coordination amongst health professionals involved in insulin initiation for people with type 2 diabetes in general practice: an exploratory survey

BACKGROUND

The majority of people with type 2 diabetes (T2D) receive their care in general practice and will eventually require initiation of insulin as part of their management. However, this is often delayed and frequently involves referral to specialists. If insulin initiation is to become more frequent and routine within general practice, coordination of care with specialist services may be required. Relational coordination (RC) provides a framework to explore this. The aim of this study was to explore RC between specialist physicians, specialist diabetes nurses (DNEs), generalist physicians in primary care (GPs) and generalist nurses (practice nurses (PNs)) and to explore the association between RC and the initiation of insulin in general practice, and the belief that it is appropriate for this task to be carried out in general practice.

METHODS

A survey was distributed to a convenience sample of specialist physicians, DNEs, GPs and practice nurses. We collected data on demographics, models of care and RC in relation to insulin initiation. We expected that RC would be higher between specialists than between specialists and generalists. We expected higher RC between specialists and generalists to be associated with insulin initiation in general practice and with the belief that it is appropriate for insulin initiation to be carried out in general practice. We used descriptive statistics and non-parametric tests to explore these hypotheses.

RESULTS

179 health professionals returned completed surveys. Specialists reported higher RC with each other and lower RC with PNs. All groups except PNs reported their highest RC with DNEs, suggesting the potential for DNEs to serve as boundary spanners. Lower RC with specialists was reported by those working within a general practice model of care. Health professionals who felt that a general practice model was appropriate reported lower communication with specialist physicians and higher shared knowledge with GPs.

CONCLUSION

Given the need for coordination between specialist and generalist care for the task of insulin initiation, this study's results suggest the need to build relationships and communication between specialist and generalist health professional groups and the potential for DNE's to play a boundary spanner role in this process.

Incidence of and risk factors for severe hypoglycaemia in treated type 2 diabetes mellitus patients in the UK--a nested case-control analysis

AIMS

To assess incidence rates (IRs) of and identify risk factors for incident severe hypoglycaemia in patients with type 2 diabetes newly treated with antidiabetic drugs.

METHODS

Using the UK-based General Practice Research Database, we performed a retrospective cohort study between 1994 and 2011 and a nested case-control analysis. Ten controls from the population at risk were matched to each case with a recorded severe hypoglycaemia during follow-up on general practice, years of history in the database and calendar time. Using multivariate conditional logistic regression analyses, we adjusted for potential confounders.

RESULTS

Of 130,761 patients with newly treated type 2 diabetes (mean age 61.7 ± 13.0 years), 690 (0.5%) had an incident episode of severe hypoglycaemia recorded [estimated IR 11.97 (95% confidence interval, CI, 11.11-12.90) per 10,000 person-years (PYs)]. The IR was markedly higher in insulin users [49.64 (95% CI, 44.08-55.89) per 10,000 PYs] than in patients not using insulin [8.03 (95% CI, 7.30-8.84) per 10,000 PYs]. Based on results of the nested case-control analysis increasing age [≥ 75 vs. 20-59 years; adjusted odds ratio (OR), 2.27; 95% CI, 1.65-3.12], cognitive impairment/dementia (adjusted OR, 2.00; 95% CI, 1.37-2.91), renal failure (adjusted OR, 1.34; 95% CI, 1.04-1.71), current use of sulphonylureas (adjusted OR, 4.45; 95% CI, 3.53-5.60) and current insulin use (adjusted OR, 11.83; 95% CI, 9.00-15.54) were all associated with an increased risk of severe hypoglycaemia.

CONCLUSIONS

Severe hypoglycaemia was recorded in 12 cases per 10,000 PYs. Risk factors for severe hypoglycaemia included increasing age, renal failure, cognitive impairment/dementia, and current use of insulin or sulphonylureas.

Predictors of hypoglycaemia in insulin-treated type 2 diabetes patients in primary care: a retrospective database analysis

AIMS

To investigate the frequency and predictors (diabetes care and treatment, comorbidity) of documented hypoglycaemia in primary care patients with insulin-treated type 2 diabetes.

METHODS

Data from 32,545 patients (mean age: 70 (SD 11) years, 50.3% males) from 1072 practices were retrospectively analyzed (Disease Analyzer database Germany: 09/2011-08/2012). Logistic regression (≥1 documented hypoglyemia) was used to adjust for confounders (age, sex, practice characteristics, diabetes treatment regimen).

RESULTS

The prevalence of patients (12 months) with at least one reported hypoglycaemia was 2.2% (95% CI: 2.0-2.4%). The adjusted odds of having hypoglycemia were increased for renal failure (OR; 95% CI: 1.26; 1.16-1.37), autonomic neuropathy (1.34; 1.20-1.49), and adrenocortical insufficiency (3.08; 1.35-7.05). Patients with mental disorders including dementia (1.49; 1.31-1.69), depression (1.24; 1.13-1.35), anxiety (1.18; 1.01-1.37), and affective disorders (1.80; 1.36-2.38) also showed an increased odds of having hypoglycemia. Location of the practice in an urban area was associated with a lower odds ratio (0.74; 0.68-0.80).

CONCLUSIONS

Both individual patient characteristics (e.g. comorbidity) and regional factors (practice location) have a substantial impact on hypoglycaemia in primary care patients with insulin therapy.

Composite efficacy parameters and predictors of hypoglycaemia in basal-plus insulin therapy--a combined analysis of 713 type 2 diabetic patients

AIMS

We aimed to identify predictors of hypoglycaemia in patients with poorly controlled type 2 diabetes treated with a single daily bolus of insulin glulisine on top of insulin glargine and oral antidiabetic drugs (basal-plus regimen).

METHODS

We retrospectively analysed four large basal-plus trials including 713 patients (47% female) with type 2 diabetes, mean age of 59.9 ± 9.5 years and diabetes duration of 11 ± 7.0 years. Predictors for symptomatic, severe and nocturnal hypoglycaemia were identified by multivariate logistic regression analyses, calculation of odds ratios (ORs) and Wald 95% confidence intervals (CIs).

RESULTS

Mean numbers of hypoglycaemic events per year were 4.64 ± 11.4 (symptomatic < 60 mg/dl), 0.59 ± 2.28 (nocturnal) and 0.03 ± 0.22 (severe). A total of 44.5% of patients reached the composite endpoint of glycated haemoglobin (HbA1c) <7.0% plus no severe hypoglycaemia, and 26.7% reached the composite of HbA1c <7.0% plus no symptomatic hypoglycaemia. Predictors of nocturnal and symptomatic hypoglycaemia were female gender (OR 1.82; 95% CI 1.07-3.11 and OR 1.89; 95% CI 1.31-2.78), diabetes duration >10 versus <5 years (OR 2.61; 95% CI 1.03-6.59 and OR 2.01; 95% CI 1.15-3.51) and higher basal insulin dose (per unit of increase) (OR 1.01; 95% CI 1.00-1.03 and OR 1.01; 95% CI 1.00-1.02). Conversely, a higher body mass index (BMI) (27-30 vs. <27 kg/m(2) and >30 vs. <27 kg/m(2) ) conferred a reduced risk of symptomatic hypoglycaemia with an OR of 0.53 (95% CI 0.31-0.90) and an OR of 0.61 (95% CI 0.39-0.97).

CONCLUSIONS

Female gender, a long diabetes duration and higher basal insulin dose were predictors of hypoglycaemia, while protection was provided by BMI > 30. These results may help to successfully establish basal-plus insulin regimen in individual patients on their transition from basal-only to basal-bolus treatment.

Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory

BACKGROUND

The majority of care for people with type 2 diabetes occurs in general practice, however when insulin initiation is required it often does not occur in this setting or in a timely manner and this may have implications for the development of complications. Increased insulin initiation in general practice is an important goal given the increasing prevalence of type 2 diabetes and a relative shortage of specialists. Coordination between primary and secondary care, and between medical and nursing personnel, may be important in achieving this. Relational coordination theory identifies key concepts that underpin effective interprofessional work: communication which is problem solving, timely, accurate and frequent and relationships between professional roles which are characterized by shared goals, shared knowledge and mutual respect. This study explores roles and relationships between health professionals involved in insulin initiation in order to gain an understanding of factors which may impact on this task being carried out in the general practice setting.

METHOD

21 general practitioners, practice nurses, diabetes nurse educators and physicians were purposively sampled to participate in a semi-structured interview. Transcripts of the interviews were analysed using framework analysis.

RESULTS

There were four closely interlinked themes identified which impacted on how health professionals worked together to initiate people with type 2 diabetes on insulin: 1. Ambiguous roles; 2. Uncertain competency and capacity; 3. Varying relationships and communication; and 4. Developing trust and respect.

CONCLUSIONS

This study has shown that insulin initiation is generally recognised as acceptable in general practice. The role of the DNE and practice nurse in this space and improved communication and relationships between health professionals across organisations and levels of care are factors which need to be addressed to support this clinical work. Relational coordination provides a useful framework for exploring these issues.