Risk factors for recurrent hypoglycemia in hospitalized diabetic patients admitted for severe hypoglycemia

Trends in Incidence of Hospitalization for Hypoglycemia and Diabetic Ketoacidosis in Individuals With Type 1 or Type 2 Diabetes With and Without Severe Mental Illness in Denmark From 1996 to 2020: A Nationwide Study

OBJECTIVE

To examine trends in incidence of acute diabetes complications in individuals with type 1 or type 2 diabetes with and without severe mental illness (SMI) in Denmark by age and calendar year.

RESEARCH DESIGN AND METHODS

We conducted a cohort study using nationwide registers from 1996 to 2020 to identify individuals with diabetes, ascertain SMI status (namely, schizophrenia, bipolar disorder, or major depression) and identify the outcomes: hospitalization for hypoglycemia and diabetic ketoacidosis (DKA). We used Poisson regression to estimate incidence rates (IRs) and incidence rate ratios (IRRs) of recurrent hypoglycemia and DKA events by SMI, age, and calendar year, accounting for sex, diabetes duration, education, and country of origin.

RESULTS

Among 433,609 individuals with diabetes, 8% had SMI. Risk of (first and subsequent) hypoglycemia events was higher for individuals with SMI than for those without SMI (for first hypoglycemia event, IRR: type 1 diabetes, 1.77 [95% CI 1.56-2.00]; type 2 diabetes, 1.64 [95% CI 1.55-1.74]). Individuals with schizophrenia were particularly at risk for recurrent hypoglycemia events. The risk of first DKA event was higher in individuals with SMI (for first DKA event, IRR: type 1 diabetes, 1.78 [95% CI 1.50-2.11]; type 2 diabetes, 1.85 [95% CI 1.64-2.09]). Except for DKA in the type 2 diabetes group, IR differences between individuals with and without SMI were highest in younger individuals (<50 years old) but stable across the calendar year.

CONCLUSIONS

SMI is an important risk factor for acute diabetes complication and effective prevention is needed in this population, especially among the younger population and those with schizophrenia.

Recurrent moderate hypoglycemia accelerates the progression of cognitive deficits through impairment of TRPC6/GLUT3 pathway in diabetic APP/PS1 mice

Currently, the most effective strategy for dealing with Alzheimer’s disease (AD) is delaying the onset of dementia. Severe hypoglycemia is strongly associated with dementia; however, the effects of recurrent moderate hypoglycemia (RH) on the progression of cognitive deficits in patients with diabetes with genetic susceptibility to AD remain unclear. Here, we report that insulin-controlled hyperglycemia slightly aggravated AD-type pathologies and cognitive impairment; however, RH significantly increased neuronal hyperactivity and accelerated the progression of cognitive deficits in streptozotocin-induced (STZ-induced) diabetic APP/PS1 mice. Glucose transporter 3–mediated (GLUT3-mediated) neuronal glucose uptake was not significantly altered under hyperglycemia but was markedly reduced by RH, which induced excessive mitochondrial fission in the hippocampus. Overexpression of GLUT3, specifically in the dentate gyrus (DG) area of the hippocampus, enhanced mitochondrial function and improved cognitive deficits. Activation of the transient receptor potential channel 6 (TRPC6) increased GLUT3-mediated glucose uptake in the brain and alleviated RH-induced cognitive deficits, and inactivation of the Ca²⁺/AMPK pathway was responsible for TRPC6-induced GLUT3 inhibition. Taken together, RH impairs brain GLUT3-mediated glucose uptake and further provokes neuronal mitochondrial dysfunction by inhibiting TRPC6 expression, which then accelerates progression of cognitive deficits in diabetic APP/PS1 mice. Avoiding RH is essential for glycemic control in patients with diabetes, and TRPC6/GLUT3 represents potent targets for delaying the onset of dementia in patients with diabetes.

Occurrence of hypoglycemia in patients with benzodiazepines poisoning: A cross-sectional study

Background

Benzodiazepine (BZD) poisoning is a common medical condition often accompanied by respiratory arrest, aspiration pneumonitis, and may rarely result in death. Although it is not studied well, hypoglycemia is a real and life-threatening condition that may occur in BZD poisoning. Thus, the present study was shown to determine the prevalence of hypoglycemia among patients with BZD poisoning compared to toxicity with other drugs.

Patients and methods

In this study, patients with drug-induced poisoning referred to Vasei hospital, Sabzevar, eastern Iran, were registered and their blood glucose levels at presentation were collected during 2019.

Results

Overall, 300 poisoned patients were evaluated (17% with BZD poisoning). The prevalence of hypoglycemia was significantly higher in patients with BZD poisoning (11.8% vs. 2.8%, p = 0.004), especially in males (P = 0.016), aged >30 years old (p = 0.006). However, the prevalence of hypoglycemia was higher in patients with GCS<10 (p = 0.005) and in patients referred later than 1 h to a medical center (p = 0.015).

Conclusion

Results were show that hypoglycemia is a frequent complication of BZD poisoning and should be considered in the initial evaluation of patients referred to the emergency department with this medical condition.

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The Occurrence of hypoglycemia in patients with Benzodiazepines poisoning.

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Benzodiazepine (BZD) poisoning is a common medical condition often accompanied by respiratory arrest, aspiration pneumonitis, and may rarely result in death.

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The hypoglycemia is a frequent complication of BZD poisoning and should be considered in the initial evaluation of patients referred to the emergency department.

An evaluation of recurrent hypoglycemia across Chicago, Illinois

AIMS

Recurrent hypoglycemia is understudied. This study evaluates recurrent hypoglycemia, fragmentation of care and mortality in a large urban center.

METHODS

The Chicago HealthLNK Data Repository (CHDR), a de-identified electronic health record data set from institutions across Chicago, identified 9741 patients with diabetes (DM) who had hypoglycemia (emergency department (ED) or inpatient admission (IA)) from 2006 to 2012. Recurrence was defined as more than one hypoglycemia encounter, and fragmentation of health care was defined as an ED visit or IA for hypoglycemia at >1 site.

RESULTS

187,644 patients were identified with DM; of 9741 patients with hypoglycemia, 2857 (29.3%) had recurrence. Patients with ≥4 hypoglycemic encounters (n = 1035) represented 10.6%, but accounted for 40.3% hypoglycemic encounters. Of 2857 patients with recurrence, 304 patients (10.6%) had fragmented care. In those with high hypoglycemic encounters (≥4), 22% (N = 226) had ≥10 encounters; race and insurance status differences were associated with number of hypoglycemic encounters. Having hypoglycemia was associated with increased mortality compared to no hypoglycemia (n = 2696, 27.7% vs n = 20,188, 11.4%; p < 0.00001 by chi-square).

CONCLUSION

A small subset of patients with hypoglycemia accounted for a large subset of hypoglycemia encounters. Targeted interventions in this high-risk, high mortality group are needed.

Effects of Co-administration of Sulfonylureas and Antimicrobial Drugs on Hypoglycemia in Patients with Type 2 Diabetes Using a Case-Crossover Design

OBJECTIVES

The purpose of this study was to investigate the effect of sulfonylureas (SUs) and antimicrobial co-administration on hypoglycemia in patients with type 2 diabetes mellitus (T2DM).

METHODS

We conducted a case-crossover study using the Korean Health Insurance Review and Assessment Service-National Inpatient Sample database, using data from 2014 to 2016. Hospitalized adult patients with T2DM who were diagnosed with hypoglycemia and prescribed SUs for at least 120 days were included. Different risk ratings of severity of drug-drug interactions were considered, including "level X, D, or C" in Lexi-Interact online and "contraindicated, major, or moderate" in Micromedex. Exposure to antimicrobials in the 30-day period before the first hypoglycemia diagnosis was assessed. Two control periods (61-90 and 91-120 days) were matched before the diagnosis date. Conditional logistic regression analysis was conducted to compare the odds of antimicrobial exposure.

RESULTS

A total of 9339 patients were included. The mean age of the patients was 71.3 ± 10.6 years, and 4818 (51.6%) were women. An increased risk of hypoglycemia was associated with co-administration of SUs and certain antimicrobials (adjusted odds ratio [aOR] 2.56, 95% confidence interval [CI] 2.34-2.80). The antimicrobial agents that were associated with an increased risk of hypoglycemia, when co-administered with SUs, were sulfonamides (aOR 2.99, 95% CI 1.99-4.52), fluoroquinolones (aOR 2.62, 95% CI 2.38-2.89), macrolides (aOR 2.48, 95% CI 1.88-3.27), and tetracyclines (aOR 1.56, 95% CI 1.05-2.33).

CONCLUSIONS

Co-administration with SUs and certain antimicrobials increased the risk of hypoglycemia. Thus, clinically relevant interactions in patients concurrently using SUs and antimicrobials should be monitored, especially within 30 days after co-administration.

Hypoglycemia prevention practice and its associated factors among diabetes patients at university teaching hospital in Ethiopia: Cross-sectional study

INTRODUCTION

Hypoglycemia is a true medical emergency, which needs prompt recognition and treatment to prevent organ damage and mortality. Knowledge about the prevention of hypoglycemia is an important step to self-care practice because informed people are more likely to have a better hypoglycemia prevention practice. The aim of this study was to explore hypoglycemia prevention practice and its associated factors among diabetes patients at a university teaching hospital in Ethiopia.

METHOD

A cross-sectional study was carried out on a total of 422 systematically selected diabetic patients at the University of Gondar Referral and Teaching Hospital. Data were collected using a pre-tested, structured, and interviewer-administered questionnaire. The collected data was analyzed by SPSS version 20 and associated variables were measured using binary logistic regression and within 95% confidence interval. A p-value <0.05 was considered as statistically significant.

RESULT

From the total of 422 diabetic patients, 61.6% were males, 70.1% of them were urban dwellers, 37.9% of them were unable to write and read, and 70.6% of the participants were taking insulin. The majority of respondents had good knowledge of (77.5%) and practice of (93.1%) hypoglycemia prevention. Only good participant knowledge about hypoglycemia prevention was strongly associated with the practice of its prevention (AOR: 2.87 (1.2-6.8), p = 0.01).

CONCLUSION AND RECOMMENDATION

Even though diabetic patients with good knowledge of hypoglycemia and its prevention was strongly associated with good prevention practice, there exists a gap in knowledge of hypoglycemia prevention. Hence, we recommend counseling be offered to patients regarding hypoglycemia during their visit to the diabetic clinic. Counseling points such as common clinical symptoms, its negative consequence, as well as remedial options are essential elements for the improvement of their practice on its prevention.

Effect of Chronic Pancreatitis on Complications and Mortality in DM Patients: A 10-year Nationwide Cohort Study

CONTEXT

Chronic pancreatitis (CP), is a long-term inflammation of the pancreatic parenchyma, and might increase risk of a hyperglycemia crisis or hypoglycemia in patients with diabetes mellitus (DM); however, the relationship has not been previously investigated.

OBJECTIVE

To investigate the risk of diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), hypoglycemia, and long-term outcomes in DM patients with CP.

DESIGN

A population-based cohort study.

SETTING AND PARTICIPANTS

Tapping Taiwan's National Health Insurance Research Database, we identified 506 DM patients with newly diagnosed CP from 1999 to 2010 and created a control cohort consisting of 5060 age- and sex-matched DM patients without CP from the same time period. We followed those 2 cohorts from the index date to occurrence of outcomes, the date of death or 31 December 2012.

MAIN OUTCOME MEASURES

DKA, HHS, hypoglycemia and mortality.

RESULTS

DM patients with CP, who were predominantly male (88%) and younger (60% < 45 years old), had a 9.5-, 5.0-, and 3.0-fold higher risk for DKA (95% confidence interval [CI]: 6.51-13.91), HHS (95% CI: 2.85-8.62), and hypoglycemia (95% CI: 2.23-4.08), respectively. They also had lower 1-, 5-, and 10-year cumulative survival rates (98.4% vs 99.0%, 87.7% vs 96.6%, and 78.7% vs 93.6%, respectively) (log-rank test: P < .001), and a 2.43-fold higher risk for death (HR: 2.43, 95% CI: 1.82-3.27).

CONCLUSIONS

In Taiwan, DM patients with CP have a higher incidence of DKA, HHS, hypoglycemia, and mortality. More attention is needed for preventing hyperglycemia crisis and hypoglycemia prevention in this population.

Hypoglycemic Risk Factors Among Hospitalized Patients with Type 2 Diabetes Mellitus at King Abdulaziz Medical City, Jeddah

Background Hypoglycemia is a pathological condition in which the serum glucose level measures less than 3.0 mmol/L. It is a well-known complication in patients with diabetes mellitus. Age, body weight, gender, insulin usage, nutritional therapy, body mass index (BMI), the presence of diabetes complications, intensive care unit admission, and infection were reported as possible risk factors that may increase the risk of hypoglycemia. Therefore, this study aimed to analyze predisposing factors for hypoglycemia among hospitalized patients with type 2 diabetes in King Abdulaziz Medical City. Method This is a retrospective, case-control study design. The study included 326 hospitalized patients with type 2 diabetes; 152 experienced hypoglycemia (blood glucose <3.9) at least once during hospitalization and have been compared to 174 in the non-hypoglycemic group (blood glucose ≥3.9). Data were extracted from their electronic medical records (EMRs). Results This study reported that patients with lower BMI (28.80 ± 7 versus 31.20 ± 12.93) experienced hypoglycemia (P-value 0.044). Those hospitalized with infections or had acquired infections or required intensive care unit (ICU) admission during hospitalization had a higher risk to develop hypoglycemia (P-value 0.005, 0.003, and <0.001, respectively). Moreover, the use of multiple doses of insulin therapy or basal-plus insulin therapy was associated with a higher risk of hypoglycemia (P-value 0.012 and 0.028, respectively). Those on supplemental insulin were less likely to develop hypoglycemia (P-value <0.001). Patients on oral feeding had a lower chance of having a hypoglycemic attack (P-value 0.002) while those on tube feeding had double the odds (OR=2.37). Conclusions Infection, intensive care unit admission, lower body mass index, insulin regimen and nutritional therapy (enteral feeding and nothing-per-mouth (NPO)) were correlated with an elevated risk of having hypoglycemia in hospitalized patients with type 2 diabetes mellitus.

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.

Frequency and Predisposing Factors for Drug-Induced Hypoglycemia in Patients with Type-2 Diabetes Mellitus

Objective:

Hypoglycemia is the most common complication of the treatment for diabetes mellitus. Various factors predispose an individual for drug-induced hypoglycemia. The aim of this study was to explore the relative frequency and likely predisposing factors for drug-induced hypoglycemia among type-2 diabetic patients in the United Arab Emirates (UAE).

Methods:

In this cross-sectional survey-based study which was conducted from February to April 2018 in two local community pharmacies in the UAE, diabetic patients underwent a structured interview on their diabetes mellitus status and management and specific open-ended questions related to hypoglycemic symptoms that they might have experienced and the occurrence of symptoms. Collected data were used to estimate the relative frequency of drug-induced hypoglycemia and to identify the probable predisposing factors and their contribution in causing hypoglycemia using relative risk, Chi-square test, and Fisher's exact test.

Findings:

The relative frequency of drug-induced hypoglycemia in our study was 46.25%. Patients' age of ≥65 years, duration of diabetes mellitus for more than 1 year, patients with more than one comorbid condition, and patients using more than one antidiabetic medication were predisposing for developing drug-induced hypoglycemia.

Conclusion:

The relative frequency of drug-induced hypoglycemia in a nontrial environment which lacks the special cares routinely provided in drug development clinical trials is high. We suggest that more attention should be paid to identify, prevent, and manage drug-induced hypoglycemia in type-2 diabetic patients who have more than 1 year of diabetes, more than one comorbidity, using more than one antidiabetic medication, and elderly.

Recurrent moderate hypoglycemia exacerbates oxidative damage and neuronal death leading to cognitive dysfunction after the hypoglycemic coma

Moderate recurrent hypoglycemia (RH) is frequent in Type 1 diabetes mellitus (TIDM) patients who are under intensive insulin therapy increasing the risk for severe hypoglycemia (SH). The consequences of RH are not well understood and its repercussions on neuronal damage and cognitive function after a subsequent episode of SH have been poorly investigated. In the current study, we have addressed this question and observed that previous RH during seven consecutive days exacerbated oxidative damage and neuronal death induced by a subsequent episode of SH accompanied by a short period of coma, in the parietal cortex, the striatum and mainly in the hippocampus. These changes correlated with a severe decrease in reduced glutathione content (GSH), and a significant spatial and contextual memory deficit. Administration of the antioxidant, N-acetyl-L-cysteine, (NAC) reduced neuronal death and prevented cognitive impairment. These results demonstrate that previous RH enhances brain vulnerability to acute hypoglycemia and suggests that this effect is mediated by the decline in the antioxidant defense and oxidative damage. The present results highlight the importance of an adequate control of moderate hypoglycemic episodes in TIDM.

Hypoglycemia- simplifying the ways to predict an old problem in the general ward

OBJECTIVE

To examine the association between hypoglycemic events and inpatient and outpatient mortality rates, and to characterize the profile of patients with diabetes who develop hypoglycemia during hospitalization in order to identify risk factors and potentially avoid it.

RESEARCH DESIGN AND METHODS

This retrospective cohort study analyzed data of 3410 patients with diabetes hospitalized during 2012. The associations among biochemical measures, severity of hypoglycemia, inpatient length of stay, and mortality during hospitalization, one month and within one year after discharge were evaluated.

RESULTS

Hypoglycemia was observed in 18.5% (633/3410) of patients with diabetes, 83% (529/633) with mild/moderate hypoglycemic values. Adjusted for age and sex, the 30-day mortality rate after discharge was higher in the group with mild/moderate hypoglycemia (HR = 1.749, CI 1.288-2.374, p < 0.001) and in the group with severe hypoglycemia (HR = 3.390, CI 2.332-6.100, p < 0.001). The mortality rate at the one-year follow-up was higher in the group with mild/moderate hypoglycemia (HR = 1.749, CI 1.288-2.374, p < 0.001) and in the group with severe hypoglycemia (HR = 3.390, CI 2.332-6.100, p < 0.001). In multivariate analysis, hemoglobin and albumin below normal values, and creatinine values above the upper limit were strongly associated with hypoglycemia (OR 1.35, 95%CI 1.1-1.6, p < 0.03; OR 1.6, 95%CI 1.33-1.89, p < 0.001; OR 1.3, 95%CI 1.08-1.55, p < 0.04, respectively).

CONCLUSIONS

Hospitalized patients with diabetes and low hemoglobin, low albumin or high creatinine levels are at increased risk of developing significant hypoglycemia. Identifying accurate high-risk factors in order to intervene early and efficiently can prevent life-threatening complications.

Real-world prevalence of mild to moderate hypoglycemic episodes in type 2 diabetes in Portugal: Results from the HIPOS-PHARMA study

AIMS

This study aimed to characterize and estimate prevalence and frequency of mild to moderate hypoglycemia and potentially associated factors in a population of type 2 diabetes mellitus (T2DM) patients treated at ambulatory care level.

METHODS

HIPOS-PHARMA was a nationwide observational, cross-sectional, multicenter study conducted in community pharmacies, which surveyed T2DM patients treated for at least 3 months.

RESULTS

Overall, 233 pharmacies recruited 1890 patients (males: 50.6%) with mean 67.1 years. On average, participants reported having diabetes for 11.8 years. A total of 86.9% had at least one chronic illness or complication of diabetes, and 76.8% were usually followed in the primary care setting. Fifty eight percent were treated without a secretagogue or insulin. Overall prevalence of mild to moderate hypoglycemic episodes in the 3 months prior to recruitment was 17.8%. A 3.13% prevalence of severe hypoglycemia was observed in the last 12 months. Results suggested that men and patients on antihyperglycemic therapies excluding secretagogues or insulin were less likely to have mild to moderate hypoglycemic episodes.

CONCLUSIONS

Mild to moderate hypoglycemic episodes were commonly reported, and factors like type of antihyperglycemic therapy, duration of disease and due complications may contribute. Almost half of episodes were not reported. Such factors should be considered in T2DM management.

Frequency of return visits to the emergency department in patients discharged following hypoglycemia episodes

BACKGROUND

In-hospital observation is typically recommended for patients who present to the emergency department with symptomatic hypoglycemia who are taking oral diabetes medications or long acting insulin. Individuals considered to be at low risk of further hypoglycemic episodes by treating providers are however on occasion discharged to home when a low suspicion of recurrence and close observation is available. We describe the frequency of hypoglycemia recurrence requiring further emergency department evaluation who have been recently discharged from the emergency department and are taking oral diabetes medications or long-acting insulin.

METHODS

A retrospective chart review was performed over a 2-year period of time at a large community-based academic emergency department for patients with an ICD-9 diagnosis of hypoglycemia who were taking oral or injectable diabetes medications. Patients were included with symptomatic blood sugar readings less than 55 mg/dL measured by prehospital or hospital providers. For those discharged from the emergency department, medical records from the study hospital and nearby health care facilities, Emergency Medical Service reports, and county death records were reviewed to determine recurrence of symptoms requiring care.

RESULTS

There were 196 patients discharged over the study period with 10 (5.1%) patients returning to the emergency department within 48 h with recurrent hypoglycemia. Return visits occurred in 4 of 144 taking insulin alone; 2.8% (CI 1.1-6.9%), in 3 of 19 patients taking oral agents alone; 15.8% (CI 5.5-37.5%), and in 3 of 33 patients taking both insulin and oral medications; 9.1% (CI 3.1-23.6%). Frequency of hypoglycemia recurrence requiring repeat ED visits was more common in those taking oral agents compared to individuals taking insulin alone (p = 0.04). All 7 individuals with recurrent hypoglycemia who were taking insulin were taking long-acting insulin preparations. No discharged patients were identified on Emergency Medical Service refusal of care reports or county death records.

CONCLUSION

Individuals discharged from the emergency department following hypoglycemic episodes who were taking oral diabetes medications are at a greater risk than individuals taking insulin alone of a return emergency department visit within 48 h for recurrent hypoglycemia.

Comorbidity of chronic kidney disease, diabetes and lower glycated hemoglobin predicts support/care-need certification in community-dwelling older adults

AIM

Chronic kidney disease (CKD), diabetes and lower glycated hemoglobin (HbA_1c ) range in diabetes patients are associated with higher mortality. We investigated whether these conditions were associated with the risk of loss of independence in community-dwelling older adults.

METHODS

We analyzed 1078 older adults with no history of support/care-need certification in Long-Term Care Insurance aged 65-94 years. Associations of baseline CKD, diabetes, and lower HbA_1c range of <6.0% in the diabetes patients, at baseline health checkup with risk of later certification and/or death for 5 years were estimated using the Cox proportional hazards regression model.

RESULTS

The prevalence of both CKD and diabetes in the total population increased with age, due to a net increase in the coexistence of CKD and diabetes. The prevalence of the lower HbA_1c range also increased with age in participants with the coexistence. During 5 years, 135 certifications and 53 deaths occurred. After adjustment, patients with comorbidity of the triad of CKD, diabetes and the lower HbA_1c range had significantly higher hazard ratios (HR) for certification (HR 3.52, 95% confidence interval [CI] 1.91-6.48, P < 0.001) and for death (HR 3.79, 95% CI 1.46-9.85, P = 0.006) compared with those without CKD and diabetes. The harmful impact of the lower HbA_1c range on later certification compared with higher HbA_1c range of ≥6.0% was maintained in diabetes patients with use of antidiabetic agents and CKD (HR 2.40, 95% CI 1.06-6.45, P = 0.036).

CONCLUSIONS

Excessive HbA_1c reduction might cause discontinuance of disability-free survival in community-dwelling older diabetes patients with CKD. Geriatr Gerontol Int 2018; 18: 521-529.

Interdisciplinary approach to compensation of hypoglycemia in diabetic patients with chronic heart failure

Diabetes mellitus is a chronic disease requiring lifelong control with hypoglycemic agents that must demonstrate excellent efficacy and safety profiles. In patients taking glucose-lowering drugs, hypoglycemia is a common cause of death associated with arrhythmias, increased thrombus formation, and specific effects of catecholamines due to sympathoadrenal activation. Focus is now shifting from merely glycemic control to multifactorial approach. In the context of individual drugs and classes, this article reviews interdisciplinary strategies evaluating metabolic effects of drugs for treatment of chronic heart failure (CHF) which can mask characteristic hypoglycemia symptoms. Hypoglycemia unawareness and cardiac autonomic neuropathy are discussed. Data suggesting that hypoglycemia modulates immune response are reviewed. The potential role of gut microbiota in improving health of patients with diabetes and CHF is emphasized. Reports stating that nondiabetic CHF patients can have life-threatening hypoglycemia associated with imbalance of thyroid hormones are discussed. Regular glycemic control based on HbA1c measurements and adequate pharmacotherapy remain the priorities in diabetes management. New antihyperglycemic drugs with safer profiles should be preferred in vulnerable CHF patients. Multidrug interactions must be considered. Emerging therapies with reduced hypoglycemia risk, telemedicine, sensor technologies, and genetic testing predicting hypoglycemia risk may help solving the challenges of hypoglycemia in CHF patients with diabetes. Interdisciplinary work may involve cardiologists, diabetologists/endocrinologists, immunologists, gastroenterologists, microbiologists, nutritionists, imaging specialists, geneticists, telemedicine experts, and other relevant specialists. This review emphasizes that systematic knowledge on pathophysiology of hypoglycemia in diabetic patients with CHF is largely lacking and the gaps in our understanding require further discoveries.

Hazardous factors besides infection in hypoglycemia

Hypoglycemia is one of the most common issues encountered in daily emergency practice. In addition to the treatment of hypoglycemia, certain other situations concomitant with hypoglycemia require further treatment. The aim of the present study was to compare demographic and clinical characteristics of infected [urinary tract infection (UTI), pneumonia or biliary tract infection (BTI)] vs. non-infected hypoglycemic patients to establish which hypoglycemic patients required further observation or hospitalization. This was a retrospective cross-sectional study of hypoglycemic (<60 mg/dl) hospitalized patients. The patients were divided into two groups: Those with hypoglycemia and concurrent infection (UTIs, pneumonia or BTIs; n=103) and non-infected hypoglycemic patients (n=83). Student's t-test was performed to analyze continuous data and the χ² test was used to analyze categorical data. Infections included 62 UTI, 43 pneumonia and 5 BTI. Comparing between the infected and non-infected groups, no significant differences were identified between mean glucose or body temperature, concurrent diagnosis (liver cirrhosis, uremia, acute renal failure, stroke or cancer) or mortality rate. Compared with the non-infected subjects, the infected patients were significantly older and had a significantly higher female ratio, as well as increased heart rates, white blood cell count and C-reactive protein levels. The present study proposes that characteristics, including concurrent stroke, liver cirrhosis and cancer are a point of focus in the initial management of hospitalized hypoglycemic patients.

Hazardous factors besides infection in hypoglycemia

Hypoglycemia is one of the most common issues encountered in daily emergency practice. In addition to the treatment of hypoglycemia, certain other situations concomitant with hypoglycemia require further treatment. The aim of the present study was to compare demographic and clinical characteristics of infected [urinary tract infection (UTI), pneumonia or biliary tract infection (BTI)] vs. non-infected hypoglycemic patients to establish which hypoglycemic patients required further observation or hospitalization. This was a retrospective cross-sectional study of hypoglycemic (<60 mg/dl) hospitalized patients. The patients were divided into two groups: Those with hypoglycemia and concurrent infection (UTIs, pneumonia or BTIs; n=103) and non-infected hypoglycemic patients (n=83). Student's t-test was performed to analyze continuous data and the χ² test was used to analyze categorical data. Infections included 62 UTI, 43 pneumonia and 5 BTI. Comparing between the infected and non-infected groups, no significant differences were identified between mean glucose or body temperature, concurrent diagnosis (liver cirrhosis, uremia, acute renal failure, stroke or cancer) or mortality rate. Compared with the non-infected subjects, the infected patients were significantly older and had a significantly higher female ratio, as well as increased heart rates, white blood cell count and C-reactive protein levels. The present study proposes that characteristics, including concurrent stroke, liver cirrhosis and cancer are a point of focus in the initial management of hospitalized hypoglycemic patients.

Epidemiology and outcomes of hypoglycemia in patients with advanced diabetic kidney disease on dialysis: A national cohort study

Background

Patients with advanced diabetic kidney disease (DKD) behave differently to diabetic patients without kidney disease. We aimed to investigate the associations of hypoglycemia and outcomes after initiation of dialysis in patients with advanced DKD on dialysis.

Methods

Using National Health Insurance Research Database, 20,845 advanced DKD patients beginning long-term dialysis between 2002 and 2006 were enrolled. We investigated the incidence of severe hypoglycemia episodes before initiation of dialysis. Patients were followed from date of first dialysis to death, end of dialysis, or 2008. Main outcomes measured were all-cause mortality, myocardial infarction (MI), and subsequent severe hypoglycemic episodes after dialysis.

Results

19.18% patients had at least one hypoglycemia episode during 1-year period before initiation of dialysis. Advanced DKD patients with higher adapted Diabetes Complications Severity Index (aDCSI) scores were associated with more frequent hypoglycemia (P for trend < 0.001). Mortality and subsequent severe hypoglycemia after dialysis both increased with number of hypoglycemic episodes. Compared to those who had no hypoglycemic episodes, those who had one had a 15% higher risk of death and a 2.3-fold higher risk of subsequent severe hypoglycemia. Those with two or more episodes had a 19% higher risk of death and a 3.9-fold higher risk of subsequent severe hypoglycemia. However, previous severe hypoglycemia was not correlated with risk of MI after dialysis.

Conclusions

The rate of severe hypoglycemia was high in advanced DKD patients. Patients with higher aDCSI scores tended to have more hypoglycemic episodes. Hypoglycemic episodes were associated with subsequent hypoglycemia and mortality after initiation of dialysis. We studied the associations and further study is needed to establish cause. In addition, more attention is needed for hypoglycemia prevention in advanced DKD patients, especially for those at risk patients.

Uric acid, renal function and risk of hypoglycaemia in Chinese type 2 diabetes patients

BACKGROUND

This study aimed to explore independent associations between serum uric acid and hypoglycaemia, and whether mildly increased serum uric acid exacerbated the association between mild decline in estimated glomerular filtration rate (eGFR) and hypoglycaemia.

METHODS

A cross-sectional survey of 6713 inpatients with type 2 diabetes and eGFR ≥60 mL/min/1.73 m² and admitted to 81 tertiary care hospitals in China was conducted. Self-reported asymptotic hypoglycaemia with plasma glucose ≤3.9 mmol/L, hypoglycaemia episodes with symptoms in 1 month or hypoglycaemia that needed assistance from other people in 3 months before hospitalization was used to define hypoglycaemia. Binary logistic regression was used to estimate odds ratios of serum uric acid for hypoglycaemia. Three measures, that is, relative excess risk due to interaction (RERI), attributable proportion due to interaction and synergy index (S) were used to estimate the effect of mildly decreased eGFR on the association of serum uric acid with hypoglycaemia.

RESULTS

Serum uric acid was associated with hypoglycaemia in an ordinal manner (P for trend <0.01) with an odds ratio of top quartile versus the lowest quartile up to 3.03 (95% confidence interval: 2.13-4.32). The odds ratio of serum uric acid levels ≥ versus <283 µmol/L (i.e. the median) was 1.98 (95% confidence interval:1.58-2.48). Serum uric acid levels ≥ versus <283 µmol/L greatly enhanced the association between mild decline in eGFR (eGFR < 90 mL/min/1.73 m² ) and hypoglycaemia from 0.94 (0.36-2.43) to 3.90 (2.55-5.95), with a significant additive interaction (P < 0.05 for RERI, AP and S).

CONCLUSIONS

Mildly increased serum uric acid was associated with increased risk of hypoglycaemia and enhanced the association between mildly decreased eGFR and hypoglycaemia in type 2 diabetes. Copyright © 2016 John Wiley & Sons, Ltd.

Current practice of hypoglycemia management in the ED

PURPOSE

To characterize hypoglycemia management and identify characteristics associated with refractory (need for additional treatment following initial management) and recurrent (adequate initial treatment followed by blood glucose [BG] ≤50 mg/dL) hypoglycemia.

METHODS

Retrospective review of adult emergency department (ED) patients who presented to a large academic medical center with hypoglycemia (BG ≤ 50 mg/dL) between January 2011 and July 2015. Data collection focused on BG measurements and treatment practices. Data are reported using descriptive statistics, Wilcoxon rank sum, and χ² analysis as appropriate.

RESULTS

Two hundred forty-four patients were included (mean age, 59 ± 18.7 years; weight, 85 ± 24.3 kg). Patients arriving via prehospital care (n = 124) were assessed faster in the ED (median, 25 minutes; interquartile range [IQR], 10-40 minutes) compared with ambulatory arrival (median, 43 minutes; IQR, 17-95 minutes; P = .0018). There were 174 patients with a BG ≤ 50 mg/dL in the ED. Of those, 108 (62.1%) were treated with intravascular bolus dextrose/intramuscular glucagon and 21 patients (12%) did not receive any treatment or food. The overall median time to treatment after identification of hypoglycemia was 12 minutes (IQR, 6-27.8 minutes); treatment was administered faster after bedside point-of-care testing assessment compared with when serum samples resulted (11 [IQR, 6-23.5] minutes vs 25 [IQR, 10.75-42.5] minutes, respectively; P = .015). The overall time to repeat BG was obtained 22 (IQR, 8-44) minutes after bolus treatment, but this interval increased with subsequent measurements. Refractory or recurrent hypoglycemia occurred in 30.3% of patients. Mean initial BG was lower in the subset of patients who developed refractory hypoglycemia compared with those who did not (35.1 ± 9.8 vs 37.6 ± 10.2 mg/dL, P = .079), although not statistically significant. Patients with recurrent hypoglycemia were also less likely to receive dextrose containing intravenous fluids compared with those without recurrent hypoglycemia (P = .028). Infection was the only associated characteristic with refractory or recurrent hypoglycemia (P = .021).

CONCLUSIONS

Overall, 12% of patients did not receive treatment for hypoglycemia in the ED with a BG ≤ 50 mg/dL. Time to treatment after identification was faster when identified by care testing vs serum sample result. Time to repeat BG in the ED was relatively quick, but did increase over time. About one-third of patients had refractory or recurrent hypoglycemia and infection was associated with this occurrence. Lack of dextrose containing intravenous fluid was associated with the incidence of recurrent hypoglycemia.

Hypoglycemia and diabetes: increased need for awareness

Hypoglycemia is an abnormally low plasma glucose concentration that may expose individuals to potential harm. It is associated with treatment of type 1 diabetes and type 2 diabetes. Diabetes-related hypoglycemia may result in various complications, reduced quality of life, and increased costs. Hypoglycemia, therefore, impacts patient management and must be considered by primary healthcare practitioners at the forefront of diabetes care. This paper reviews the impact of hypoglycemia on patients and healthcare practitioners in the clinical setting. Recognizing hypoglycemia and its risk factors and identifying high-risk patients can assist with prevention and management. Prevention rather than treatment of hypoglycemia is preferable by individualizing glycemic goals, considering hypoglycemia risk factors, and continuing professional support. Education of patients and healthcare practitioners is also a key factor in hypoglycemia prevention. Although several newer-generation therapies and treatment strategies for type 2 diabetes have a lower risk of hypoglycemia than established agents, long-term safety data are currently lacking. Thus, choice of therapy is important, with hypoglycemic risk varying according to drug selection.

Cardiovascular Disease Predicts Severe Hypoglycemia in Patients with Type 2 Diabetes

BACKGROUND

To investigate whether a history of prior cardiovascular disease (CVD) is associated with severe hypoglycemia (SH) in patients with type 2 diabetes.

METHODS

We conducted a prospective cohort study from January 2001 to December 2012 with a median follow-up time of 9.5 years (5,814 person-years). Patients aged 25 to 75 years with type 2 diabetes and without chronic kidney disease were enrolled (n=894), and 624 patients completed follow-up. SH was defined as hypoglycemic episodes requiring hospitalization or medical care in an emergency department. We used the Cox proportional hazards regression analysis to test associations between SH episodes and potential explanatory variables.

RESULTS

Among the 624 participants who completed follow-up, 60 patients (9.6%) had previous CVD. Compared to patients without CVD, patients with previous CVD were older, had a longer duration of diabetes and hypertension, received more insulin, and had more diabetic microvascular complications at baseline. During follow-up, 62 patients (9.9%) experienced at least one SH episode (incidence of 1.33 per 100 patient-years). The development of SH was associated with a history of CVD (hazard ratio, 1.99; 95% confidence interval, 1.07 to 3.72; P=0.031) after adjusting for sex, age, diabetic duration, hypertension, hemoglobin A1c levels, diabetic complications, cardiovascular autonomic neuropathy, and insulin use.

CONCLUSION

A history of CVD was an independent risk factor for the development of SH in patients with type 2 diabetes mellitus. For patients with CVD, modulation of glycemic targets and diabetic education for the prevention of hypoglycemia should be implemented.

Streptozotocin Induced Acute Clinical Effects in Rabbits (Oryctolagus cuniculus)

BACKGROUND & OBJECTIVES

Streptozotocin (STZ) is used for induction of Type-1 diabetes mellitus in animal models. Its beta-cytotoxic action results in sudden release of insulin leading to severe hypoglycaemia and even mortality. However, its sensitivity varies with species. Present investigation was aimed at studying STZ induced acute clinical effects in rabbits.

METHODS

Streptozotocin @ 65 mg/kg b.w. was administered to thirteen New Zealand White rabbits, 1-1.5 kg body weight, as single intravenous dose in 1mL citrate buffer, pH 4.6. Blood glucose levels were recorded before drug administration and then at 20 min, 1h, and hourly up to 9 hours post-treatment followed by intravenous and oral glucose therapy. Clinical signs were noted.

RESULTS

STZ caused immediate hyperglycaemia up to 4 hours, and then progressively severe hypoglycaemia up to 9 hours. Hypoglycaemia caused characteristic behavioural alterations including lethargy, dullness, sitting quietly but appearing alert, followed by aesthesia and then muscular weakness with characteristic postural changes starting from drooping of head and torticollis, Rabbits recovered following glucose therapy. Marked individual variations in response vis-a-vis onset and severity of glycaemic changes were observed.

CONCLUSION

STZ induced a characteristic multiphasic immediate response in rabbits similar to one reported in other rodents. Behavioural changes were characteristic of hypoglycaemia warranting early management in order to avoid fatalities.

Effectiveness and safety of basal supported oral therapy with insulin glargine, in Japanese insulin-naive, type 2 diabetes patients, with or without microvascular complications: subanalysis of the observational, non-interventional, 24-week follow-up Add-on Lantus® to Oral Hypoglycemic Agents (ALOHA) study

AIMS

The aim of this study is to evaluate effectiveness and safety of basal supported oral therapy (BOT) using insulin glargine in insulin-naive Japanese patients, with and without microvascular complications.

METHODS

This sub-group analysis of observational, non-interventional ALOHA study, assessed changes in glycemic parameters and glargine dose, at 24weeks or at glargine discontinuation. Count of hypoglycemic episodes was based on physicians' documentation of patient reports. Patients were stratified according to presence/absence of microvascular complications, at baseline. Relationships between baseline patient characteristics and achievement of HbA1c <7% were examined by multivariate regression analysis.

RESULTS

A total of 3631 patients, included during 2007-2009, were stratified in sub-groups: no complications (n= 1889), retinopathy (n=318), neuropathy (n=297), nephropathy (n=356), retinopathy+neuropathy (n= 174), retinopathy+nephropathy (n=154), neuropathy+nephropathy (n=142), and retinopathy+neuropathy+nephropathy (n=301). Changes in HbA1c, fasting and postprandial plasma glucose, and glargine daily dose were similar among patients with and without complications. Response-rate for achieving HbA1c <7.0% was highest in patients without complications (19.1%). In multivariate analysis, patients without complications showed significantly higher odds of attaining HbA1c <7%, independent of diabetes duration and baseline HbA1c levels. Patients with retinopathy+nephropathy had the lowest response-rate (8.8%) and highest hypoglycemic-rate (3.2%).

CONCLUSION

Japanese insulin-naive patients without complications, on BOT with glargine, show higher chances of attaining HbA1c <7.0% than those with complications.

Severe hypoglycemia rates and associated costs among type 2 diabetics starting basal insulin therapy in the United States

OBJECTIVES

To derive current real-world data on the rates and costs of severe hypoglycemia (SH) for people with type 2 diabetes mellitus (T2D) who have initiated basal insulin therapy and to examine differences in SH rates and costs stratified by history of prior SH events.

METHODS

We used a nation-wide electronic health records database that included encounter and laboratory data, as well as clinical notes, to estimate the rates and costs of SH events among adults with T2D who initiated basal insulin between 2008 and 2011. Unadjusted and regression-adjusted rates and quarterly costs were calculated for all patients as well as stratified by history of a SH event before starting basal insulin and history of a SH event during the basal insulin titration period.

RESULTS

We identified 7235 incident cases of basal insulin use among patients with T2D who did not use insulin during the previous 12 months. Regression-adjusted incidence and total event rates were 10.36 and 11.21 per 100 patient-years, respectively. A history of SH events during the pre-index baseline and post-index titration periods were statistically significantly associated with both the incidence and total event rates (p < 0.01). Regression-adjusted total healthcare and diabetes-related costs were statistically significantly (p < 0.01) higher in those quarters when a SH event occurred than in those quarters without any SH events ($3591 vs. $487 and $3311 vs. $406, respectively). A history of previous SH or SH events during the titration period were not statistically significantly associated with costs.

CONCLUSIONS

These results suggest that the real-world burden of SH is high among people with T2D who start using basal insulin and that history of previous SH events, both before starting insulin and during the insulin titration period, influences future SH. These results can also provide insights into interventions that can prevent or delay SH. These results should, however, be interpreted in light of the key limitations of our study: not all SH events may have been captured or coded in the database, data on filled prescriptions were not available, and the post-titration follow-up period could have been divided into time units other than quarters (3 month blocks) resulting in potentially different conclusions. Further real-world studies on the frequency and costs of SH, using methods to identify as many SH events as possible, can allow healthcare providers to make more informed decisions on the risks and benefits of basal insulin therapy in T2D patients.

Incidence and predictors of hypoglycemia in Japanese patients with type 2 diabetes treated by insulin glargine and oral antidiabetic drugs in real-life: ALOHA post-marketing surveillance study sub-analysis

BACKGROUND

Add-on Lantus® to Oral Hypoglycemic Agents (ALOHA), an observational, non-interventional, 24-week post-marketing surveillance study in Japanese patients with type 2 diabetes (T2DM) having uncontrolled glycemic control, demonstrated that basal supported oral therapy (BOT) with insulin glargine was an effective and safe treatment in real-life clinical practice. We performed subgroup analysis to identify incidence and predictors associated with risk of hypoglycemia.

METHODS

Among 4219 patients with T2DM, 3732 patients were insulin-naïve and 487 patients were insulin non-naïve who switched from other insulin to insulin glargine. All hypoglycemic episodes were counted by physicians' documentation based on patients' reports. Relationships between baseline patient characteristics and glargine-related hypoglycemic episodes were examined by univariate and multivariate analysis.

RESULTS

Among 4219 patients, 44 (1.0%) patients experienced hypoglycemic episodes (41 insulin-naïve patients; 3 insulin non-naïve patients), with a rate of incidence 0.035 episodes/patient-years. Majority of patients with hypoglycemia (37 of 44) had just one hypoglycemic episode during study period. Among insulin-naïve patients, incidence of hypoglycemia differed significantly depending on age, diabetic complications, estimated glomerular filtration rate (eGFR), and postprandial plasma glucose (P <0.05). In a multivariate adjusted model, poor renal function (eGFR <60 mL/min/1.73 m2) was a statistically significant risk factor (P < 0.05).

CONCLUSION

Our results suggest that BOT using insulin glargine is an option of insulin therapy with 1% risk of hypoglycemia in patients with T2DM with inadequate glycemic control. Patients with low renal function might need a careful follow-up.

Neuronal damage and cognitive impairment associated with hypoglycemia: An integrated view

The aim of the present review is to offer a current perspective about the consequences of hypoglycemia and its impact on the diabetic disorder due to the increasing incidence of diabetes around the world. The main consequence of insulin treatment in type 1 diabetic patients is the occurrence of repetitive periods of hypoglycemia and even episodes of severe hypoglycemia leading to coma. In the latter, selective neuronal death is observed in brain vulnerable regions both in humans and animal models, such as the cortex and the hippocampus. Cognitive damage subsequent to hypoglycemic coma has been associated with neuronal death in the hippocampus. The mechanisms implicated in selective damage are not completely understood but many factors have been identified including excitotoxicity, oxidative stress, zinc release, PARP-1 activation and mitochondrial dysfunction. Importantly, the diabetic condition aggravates neuronal damage and cognitive failure induced by hypoglycemia. In the absence of coma prolonged and severe hypoglycemia leads to increased oxidative stress and discrete neuronal death mainly in the cerebral cortex. The mechanisms responsible for cell damage in this condition are still unknown. Recurrent moderate hypoglycemia is far more common in diabetic patients than severe hypoglycemia and currently important efforts are being done in order to elucidate the relationship between cognitive deficits and recurrent hypoglycemia in diabetics. Human studies suggest impaired performance mainly in memory and attention tasks in healthy and diabetic individuals under the hypoglycemic condition. Only scarce neuronal death has been observed under moderate repetitive hypoglycemia but studies suggest that impaired hippocampal synaptic function might be one of the causes of cognitive failure. Recent studies have also implicated altered mitochondrial function and mitochondrial oxidative stress.

Managing diabetes in Asia: overcoming obstacles and the role of DPP-IV inhibitors

Asia bears the world's greatest burden of type 2 diabetes (T2DM) and prevalence is increasing rapidly. Compared to other races, Asians develop T2DM younger, at a lower degree of obesity, suffer longer from its complications and die earlier. Curbing this epidemic requires an integrated, risk-based, and multidisciplinary approach. Inadequately managed T2DM has macrovascular and microvascular sequelae, Asians with T2DM being particularly susceptible to diabetic nephropathy. Earlier and more intensive monitoring and management of risk factors are required, especially for patients with, or at risk of, renal impairment. Particular challenges of T2DM management in Asia include: lack of access to specialist healthcare, insufficient clinical evaluation and delayed diagnosis. As in Caucasians, conventional treatment modalities are limited by deteriorating glycaemic control with disease progression and there is an unmet need for efficacious, safe, cost-effective and convenient pharmacotherapies for treating different stages of T2DM and preventing its complications, particularly in high-risk patients. There is a trend towards increasing use of DPP-IV inhibitors, which are no less efficacious and safe in Asians than Caucasians and may have some advantages over existing oral antidiabetic agents, particularly for certain high-risk groups. Such agents may play a significant future role in the management of T2DM.

Hypoglycemia revisited in the acute care setting

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