Flying under the radar in the last few decades have been an epidemic of emergency department visits and hospitalization related to insulin-related hypoglycemia. But recently researchers (Geller 2014), using 2 large national data sources, found that there were an estimated 97,648 ED visits annually related to insulin-related hypoglycemia. Moreover, almost one-third (29.3%) resulted in hospitalization and severe neurological sequelae were estimated to occur in 60%. Insulin-treated patients 80 years or older were more than twice as likely to visit the ED and nearly 5 times as likely to be subsequently hospitalized.
Geller et al. note that the number of patients in the US taking insulin has increased 50% over the last decade. When they looked at reasons for the hypoglycemia, the most commonly identified precipitants were reduced food intake and administration of the wrong insulin product. While almost half of the cases noted a meal-related misadventure, 22% involved the patient taking a wrong insulin product and 12% a wrong dose. One of the biggest problems was the patient taking a rapid-acting insulin rather than the intended long-acting one.
They recommend focusing efforts on education of patients on several aspects of insulin use, including having patients demonstrate to providers their understanding and simulation. They also call for continued efforts to better differentiate the various insulin products. They also note a trend in recent diabetes treatment guidelines to relax targets in patients with advanced age, short life expectancies, and high risk of hypoglycemia.
In an accompanying commentary Sei J. Lee (Lee 2014) puts this trend in perspective, noting that the 100,000 ED visits annually for hypoglycemia have gotten far less attention than the 715,000 annual MI’s despite the fact that most hypoglycemia is caused by the health care system. Lee also points a finger at the pharmaceutical industry for its role in driving guidelines to aim for tighter glucose control and lower HbA1c levels. Lee notes that the ACCORD trial in type II diabetics showed increased mortality when patients are treated to an overly aggressive HbA1c target (mean HbA1c 6.4%). Lee recommends that rather than prescribing a target for HbA1c, specifying a range might be more likely to remind us not to overtreat. Also we need to be very careful that widely-used quality metrics do not inadvertently drive overtreatment. Lastly, Lee raises the question of avoiding insulin all together in patients age 80 years and older.
Geller AI, Shehab N, Lovegrove MC, et al. National Estimates of Insulin-Related Hypoglycemia and Errors Leading to Emergency Department Visits and Hospitalizations. JAMA Intern Med 2014; Published online March 10, 2014
Lee SJ. So Much Insulin, So Much Hypoglycemia. JAMA Intern Med 2014; Published online March 10, 2014
The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med 2008; 358: 2545-2559
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