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Intensive Treatment & Risk of Hypoglycemia

JAMA Intern Med; 2016 Jul; McCoy, Lipska, et al

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Among patients with type 2 diabetes, >20% received intensive glucose-lowering treatment that may be unnecessary; and this intensive treatment nearly doubles the risk of severe hypoglycemia among those with high clinical complexity. This according to a study of nonpregnant adults aged ≥18 years with type 2 diabetes from January 1, 2001, through December 31, 2013 who achieved and maintained a hemoglobin A1c level <7.0% without use of insulin and had no episodes of severe hypoglycemia in the prior 12 months. Researchers found:

• Of 31,542 eligible patients (median age 58 years, 49.1% women, 57.7% white), 3,910 (12.4%) had high clinical complexity, defined as being 75 years or older, having dementia or end-stage renal disease, or having 3 or more serious chronic conditions.

• There was a 25.7% risk-adjusted probability of intensive treatment in patients with low clinical complexity vs 20.8% in patients with high clinical complexity.

• In patients with low clinical complexity, over 2 years, the risk-adjusted probability of severe hypoglycemia was 1.02% with standard treatment vs 1.30% with intensive treatment.

• In patients with high clinical complexity, intensive treatment significantly increased the risk-adjusted probability of severe hypoglycemia from 1.74% with standard treatment to 3.04% with intensive treatment.

Citation: McCoy RG, Lipska KJ, Yao X, Ross JS, Montori VM, Shah ND. Intensive treatment and severe hypoglycemia among adults with type 2 diabetes. JAMA Intern Med. 2016;176(7):969-978. doi:10.1001/jamainternmed.2016.2275.

Commentary: When managing patients with diabetes, recent guidelines have emphasized that in addition to managing hyperglycemia, it is important to try to minimize the occurrence of hypoglycemia. An individualized approach is recommended in setting A1c targets, with the usual A1c target of <7% for most patients, but a more lenient approach, with a A1c above 7% for patients who are older or who have multiple comorbidities. This study illustrates that for any target A1c, patients who are older and sicker tend to have a high frequency of hypoglycemia than those who are younger. When intensive glucose targets are set for complex patients, the frequency of hypoglycemia goes up a great deal. This supports the recommendations of the American Geriatrics Society (AGS) Choosing Wisely campaign that recommends against use of medications other than metformin to achieve a HbA1c level of <7.5% in most older adults with diabetes because of the risk of hypoglycemia.1 In addition, it should make us think about de-escalation of therapy in older adults who have low A1c’s, as clinical inertia is an issue germane not just to intensification of therapy but to de-escalation as well. —Neil Skolnik, MD

1. AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014;62(5):950-960.

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