Hypoglycaemia, emergency care and diabetes mellitus

1. Hypoglycaemia, emergency care and diabetes mellitus Moheet, A. & Seaquist, E. R. Nat. Rev. Endocrinol. 10, 384–385 (2014)

2. Introduction • Iatrogenic hypoglycaemia is a common adverse effect of insulin therapy for patients with diabetes mellitus • Hypoglycaemic events are associated with considerable morbidity, which can limit the ability of patients to achieve a level of glycaemic control that can prevent long-term complications of diabetes mellitus • Hypoglycaemic events can also be fatal. In addition, these events are a common cause of visits to the emergency department and subsequent hospitalizations, as demonstrated in a recent study by Geller and colleagues

3. Introduction • These episodes of hypoglycaemia, which are costly with respect to both health-care resources and patient outcomes, are presumably avoidable • The responsibility lies with clinicians to effectively manage treatment protocols to prevent patients from having such severe hypoglycaemia that they require the assistance of emergency personnel

4. Methods • In their investigation, Geller and colleagues used data from two nationally representative surveys to estimate the rates of insulin-related hypoglycaemia that resulted in visits to emergency departments and subsequent hospitalizations in the USA • The National Health Interview Survey was used to estimate the total number of patients with diabetes mellitus who were treated with insulin or an oral antidiabetic agent

5. Results • From these data, Geller and colleagues estimated that >97,000 visits to emergency departments resulted from iatrogenic hypoglycaemia each year • This represents almost 10% of all of the emergency department visits as a result of adverse drug reactions during the period of the survey • The number of visits was particularly high in the elderly • In patients taking insulin, those ≥80 years old were more than twice as likely as those aged

6. Discussion • The risk of hypoglycaemia is believed to be increased in patients striving to achieve near-normal glycaemic level • However, few clinical trials have examined the risks and benefits of intensive glycaemic control in patients with diabetes mellitus >70 years old • Large clinical trials in patients with diabetes mellitus have demonstrated beneficial effects of intensive glycaemic control on rates of microvascular complications

7. Discussion • However, these results are not directly applicable to patients >70 years old with diabetes mellitus and multiple comorbidities • In the ACCORD study, the incidence of severe hypoglycaemia was three times higher in the group that received intensive therapy than in the standard therapy group • Post hoc analysis of the ACCORD trial showed that the risk of mortality was increased in participants who experienced severe hypoglycaemia

8. Discussion • Analysis of data from the UK General Practice Research Database, demonstrated a U‑shaped association between circulating levels of HbA1c and an increased incidence of all-cause mortality and cardiac events in patients with T2DM who were aged ≥50 years • This observation suggests that both extreme hyperglycaemia and hypoglycaemia contribute to poor outcomes

9. Conclusion • Glycaemic targets and diabetic therapy should be individualized according to patient age, duration of diabetes mellitus, life expectancy and other medical considerations • Many of the precipitating factors that can lead to severe hypoglycaemia are preventable • Increased education for patients and caregivers on how to prevent, recognize and treat hypoglycaemia is critical • Patients should be screened regularly to detect previous episodes of severe hypoglycaemia and impaired hypoglycaemia awareness

10. Conclusion • Additional studies are needed to improve understanding of the relationship between glycaemic targets and the risk of hyperglycaemia in older adults with diabetes mellitus • Such studies are particularly important for individuals with multiple comorbidities, so that management strategies can be developed to provide maximum benefit to these patients without exposing them to the risk of severe hypoglycaemia

11. Conclusion • New classes of antidiabetic medications that do not cause hypoglycaemia have become available in the past decade • However, additional research is needed to examine the role of these medications in the treatment of patients with diabetes mellitus who are >70 years • In the future, we may find that the description selected by Geller and colleagues for their work applies to the use of insulin in elderly patients with diabetes mellitus: less is more