Hospital utilization for hypoglycemia among patients with type 2 diabetes using pooled data from six health systems

Young adults with type 2 diabetes experience high rates of Level 3 Hypoglycemia: A subgroup analysis of the Real-World iNPHORM cohort

AIMS

This study evaluated the incidence of self-reported Level 3 hypoglycemia and explored associated risk factors in young adults with type 2 diabetes (T2D).

METHODS

Subgroup analyses with a one-year U.S.-wide T2D dataset were performed. Retrospective and prospective data on Level 3 hypoglycemia and participant characteristics were analyzed for 207 young adults (18-39 years old) and 436 middle-aged adults (40-64 years old). Age group-stratified multivariable negative binomial regression was used to identify factors associated with Level 3 hypoglycemia.

RESULTS

Young adults exhibited a threefold higher prevalence of Level 3 hypoglycemia events requiring medical assistance compared to the middle-aged cohort at baseline (p < 0.001). During follow-up, the young adults experienced a twofold higher prevalence of Level 3 hypoglycemia (p < 0.001), resulting in a fivefold higher rate of Level 3 hypoglycemia (p < 0.001) and greater hypoglycemia fear (p < 0.001). Distinct sociodemographics, general health and lifestyle factors, diabetes medical history, and diabetes therapy and technology use characteristics were observed in the young-adult group, as were unique risk factors for Level 3 hypoglycemia.

CONCLUSION

Our findings suggest that young adults with T2D are at particularly high risk of Level 3 hypoglycemia, with attributes that differ from those of the traditional middle-aged cohort.

Hypoglycemic Events May Trigger Acute Ischemic Stroke Within 30 Days in Those With Diabetes: A Case-Crossover Study

BACKGROUND

Stroke triggers are factors that may precipitate a stroke within a given time interval and can predict the timing of a stroke. While hypoglycemia has been established as a risk factor for cardiovascular events such as acute ischemic stroke (AIS), there is limited research demonstrating hypoglycemic events as stroke triggers. We hypothesize an association between hypoglycemic events and the occurrence of stroke among patients with diabetes.

METHODS

We used Medicare inpatient, outpatient, emergency department, and subacute nursing facility data sets from January 1, 2016, to December 31, 2019, and validated using International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify conditions. We used a case-crossover study design, testing whether exposure to a hypoglycemia encounter within progressively longer case periods (up to 30 days before index AIS) was associated with the subsequent occurrence of AIS, compared with control periods of equal length exactly 1 year before the case period. We used conditional logistical regression models to estimate odds ratios and 95% CIs.

RESULTS

There were 237 667 index admissions with AIS and diabetes during the study period. There were increased odds of AIS following an encounter with hypoglycemia. The risk was the highest immediately on the first day following the hypoglycemia encounter (odds ratio, 3.694 [95% CI, 2.694-5.065]; P<0.0001) and gradually became lower as the case-control period lengthened. At a 30-day case-control interval, the risk was lowest but still significant (odds ratio, 2.345 [95% CI, 2.179-2.523]; P<0.0001).

CONCLUSIONS

We found that hypoglycemic events in patients with diabetes are associated with a more than 3-fold greater risk of AIS in the first day but can trigger AIS in the 30 days following the event. More research is needed to assess the link between the severity of hypoglycemia and stroke occurrence, as well as the severity of the stroke. These results, if confirmed in other studies, emphasize the importance of avoiding hypoglycemic events in patients with diabetes.

6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Development and Validation of a Nocturnal Hypoglycaemia Risk Model for Patients With Type 2 Diabetes Mellitus

AIM

To develop and test different machine learning algorithms for predicting nocturnal hypoglycaemia in patients with type 2 diabetes mellitus.

DESIGN

A retrospective study.

METHODS

We collected data from dynamic blood glucose monitoring of patients with T2DM admitted to the Department of Endocrinology and Metabolism at a hospital in Shanghai, China, from November 2020 to January 2022. Patients undergone the continuous glucose monitoring (CGM) for ≥ 24 h were included in this study. Logistic regression, random forest and light gradient boosting machine algorithms were employed, and the models were validated and compared using AUC, accuracy, specificity, recall rate, precision, F1 score and the Kolmogorov-Smirnov test.

RESULTS

A total of 4015 continuous glucose-monitoring data points from 440 patients were included, and 28 variables were selected to build the risk prediction model. The 440 patients had an average age of 62.7 years. Approximately 48.2% of the patients were female and 51.8% were male. Nocturnal hypoglycaemia appeared in 573 (14.30%) of 4015 continuous glucose monitoring data. The light gradient boosting machine model demonstrated the highest predictive performances: AUC (0.869), specificity (0.802), accuracy (0.801), precision (0.409), recall rate (0.797), F1 score (0.255) and Kolmogorov (0.603). The selected predictive factors included time below the target glucose range, duration of diabetes, insulin use before bed and dynamic blood glucose monitoring parameters from the previous day.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

A National Physician Survey Examining Switching From Sulfonylureas or Insulin to Newer Diabetes Medications

This study was a national survey of U.S. physicians in general medicine, geriatrics, or endocrinology who were asked what medication change they would make for adults with type 2 diabetes taking sulfonylureas or insulin with an A1C below their individualized goal. Responding physicians switched the hypoglycemia-causing medication a median of 4 times (interquartile range 1-9) among 27 opportunities and selected dipeptidyl peptidase 4 inhibitors most often when switching. Sodium-glucose cotransporter 2 inhibitors were selected less frequently, including when indicated for cardiovascular and renal comorbidities, but significantly more often among physicians caring for a greater proportion of patients with private health insurance. Overcoming barriers to switching hypoglycemia-causing medications may help to reduce rates of hypoglycemia while targeting cardiovascular and renal comorbidities.

A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications

BACKGROUND

Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice.

OBJECTIVE

To understand physicians' decision-making around deintensifying diabetes treatment.

DESIGN

National physician survey.

PARTICIPANTS

US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care.

MAIN MEASURES

Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models.

KEY RESULTS

There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003).

CONCLUSIONS

While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.

Ongoing burden and recent trends in severe hospitalised hypoglycaemia events in people with type 1 and type 2 diabetes in Scotland: A nationwide cohort study 2016-2022

AIMS

We examined severe hospitalised hypoglycaemia (SHH) rates in people with type 1 and type 2 diabetes in Scotland during 2016-2022, stratifying by sociodemographics.

METHODS

Using the Scottish National diabetes register (SCI-Diabetes), we identified people with type 1 and type 2 diabetes alive anytime during 2016-2022. SHH events were determined through linkage to hospital admission and death registry data. We calculated annual SHH rates overall and by age, sex, and socioeconomic status. Summary estimates of time and stratum effects were obtained by fitting adjusted generalised additive models using R package mgcv.

RESULTS

Rates for those under 20 with type 1 diabetes reached their minimum at the 2020-2021 transition, 30% below the study period average. A gradual decline over time also occurred among 20-49-year-olds with type 1 diabetes. Overall, females had 15% higher rates than males with type 2 diabetes (rate ratio 1.15, 95% CI 1.08-1.22). People in the most versus least deprived quintile experienced 2.58 times higher rates (95% CI 2.27-2.93) in type 1 diabetes and 2.33 times higher (95% CI 2.08-2.62) in type 2 diabetes.

CONCLUSIONS

Despite advances in care, SHH remains a significant problem in diabetes. Future efforts must address the large socioeconomic disparities in SHH risks.

Medication-Related Hospital Admissions and Emergency Department Visits in Older People with Diabetes: A Systematic Review

Limited data are available regarding adverse drug reactions (ADRs) and medication-related hospitalisations or emergency department (ED) visits in older adults with diabetes, especially since the emergence of newer antidiabetic agents. This systematic review aimed to explore the nature of hospital admissions and ED visits that are medication-related in older adults with diabetes. The review was conducted according to the PRISMA guidelines. Studies in English that reported on older adults (mean age ≥ 60 years) with diabetes admitted to the hospital or presenting to ED due to medication-related problems and published between January 2000 and October 2023 were identified using Medline, Embase, and International Pharmaceutical Abstracts databases. Thirty-five studies were included. Medication-related hospital admissions and ED visits were all reported as episodes of hypoglycaemia and were most frequently associated with insulins and sulfonylureas. The studies indicated a decline in hypoglycaemia-related hospitalisations or ED presentations in older adults with diabetes since 2015. However, the associated medications remain the same. This finding suggests that older patients on insulin or secretagogue agents should be closely monitored to prevent potential adverse events, and newer agents should be used whenever clinically appropriate.

6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Glycated haemoglobin trajectories and one-year risk of potentially avoidable hospitalisations among adult type 2 diabetes patients seeking care at specialist outpatient clinics of a tertiary hospital: a cohort study

AIM

To evaluate the association between trajectories of glycated haemoglobin (HbA1c) and potentially avoidable hospitalisations (PAH).

METHODS

We performed a cohort study in a tertiary hospital in Singapore among adult type 2 diabetes patients with ≥3HbA1c tests over two years. Then, we followed up for one year after the last HbA1c reading. Glycaemic control was analysed by (1)HbA1c trajectories through group-based trajectory modelling, and (2)mean HbA1c. PAH was defined using the Agency of Healthcare Research and Quality criteria, categorising as overall, acute, chronic, diabetes-composites.

RESULTS

A total of 14923 patients (mean age:62.9±12.8 years;55.2% men)were included. Four HbA1c trajectories were observed; low-stable(n=9854,66.0%), moderate-stable(n=3125,20.9%), high-decrease(n=1017,6.8%) and high-persistent(n=927,6.2%). Compared to the low-stable trajectory, one-year risk ratio(RR) and 95%CI, respectively for moderate-stable, high-decrease and high-persistent trajectories were as follows:(1)overall PAH:1.15(1.00-1.31),1.53(1.31-1.80),1.96(1.58-2.43);(2)diabetes PAH:1.30(1.04-1.64),1.98(1.55-2.53),2.24(1.59-3.15);(3)acute PAH:1.14(0.90-1.44),1.29(0.95-1.77),1.75(1.17-2.62); and (4)chronic PAH:1.21(1.02-1.43),1.62(1.34-1.97),2.14(1.67-2.75). Mean HbA1c was significantly associated with overall and chronic-composites of PAH whilst evidence of a non-linear relationship with diabetes-composite of PAH was noted.

CONCLUSION

Patients with high-decrease trajectory had a risk lower than those with persistently-high HbA1c, highlighting that a greater risk of hospitalisation conferred by poor glycaemic control is potentially reversible. Determining HbA1c trajectories could help to identify the high-risk individuals for targeted and intensive management to improve care and reduce hospitalisations.

A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications

BACKGROUND

While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs.

OBJECTIVE

To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications.

DESIGN

This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated.

PARTICIPANTS

Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty.

APPROACH

Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous.

KEY RESULTS

Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively.

CONCLUSIONS

Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.