Type 2 Diabetes and Hypoglycemia: If You Use Insulin, You're at Risk, too

Written by Ilene Raymond Rush

Hypoglycemia in patients with type 2 diabetes who take insulin or sulfonylureas presents a serious and underappreciated public health issue, according to an “environmental scan” from the Endocrine Society published in the Journal of Clinical Endocrinology & Metabolism. 1

If a person with diabetes takes too much insulin, their blood sugar drops and can lead to hypoglycemia. Sulfonylureas, oral medications that work to lower blood glucose by helping the pancreas create more insulin and cells to use insulin more effectively, can also cause reductions in blood sugar.

Symptoms of mild or moderate hypoglycemia include shakiness, sweating, hunger, nervousness and increased heart rate. Severe hypoglycemia can cause seizures, loss of consciousness and death. A recent meta-analysis concluded that individuals who take insulin to treat type 2 diabetes experience an average of 23 mild or moderate events and one severe hypoglycemic episode in a year. 2

It’s been estimated that around 300,000 individuals who were type 1 or type 2 patients required emergency care for this condition in 2009.3

About 30 to 40% of people with type 2 diabetes take insulin. Since type 2 is a progressive disease, as the pancreas loses its ability to produce insulin, many older patients move onto insulin therapy.

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The report notes that hypoglycemia mainly affects patients who are older, over 65, as well as patients with chronic kidney disease or with conditions such as frailty, chronic liver disease, or malnutrition.

“While hypoglycemia is recognized as a threat among people with type 1 diabetes and their health care providers, the danger it poses to people with type 2 diabetes is underappreciated,” said  Robert W. Lash, MD, the society’s chief professional and clinical affairs officer and lead author. “We need to be aware that emphasizing lower blood glucose goals may unintentionally put individuals with type 2 diabetes at greater risk of hypoglycemia.”

The scan, completed by Dr. Lash and colleagues from Avalere Health in Washington, D.C., analyzed 31 articles from the literature and the Internet for information on clinical practices and hypoglycemia and type 2 patients.It showed that clinicians, “lack the resources to identify, assess and manage patients who are at a high risk of developing hypoglycemia.”

Reducing the Risk of Hypoglycemia 

To address this problem, the Society is launching a pilot initiative designed to assess a number of interventions to reduce hypoglycemia risk in high-risk patients with type 2 diabetes.

“There’s been a big emphasis in treating patients with type 2 diabetes to get glucose levels down,” said Dr. Lash. “If you look at the ways physicians get “graded” for their management of diabetes most of them are related to how low they can get A1C sugars, but there are no quality measurements available to assess whether is getting a low blood sugar. So one of our goals is to come up with some quality measures that would reflect the importance of not having a low blood sugar that could be used in conjunction with some other aspects of diabetes—such as good glucose control or good blood pressure control.”

“Not surprisingly, our findings suggest that interventions to reduce hypoglycemia should focus on helping clinicians identify high-risk patients who would most benefit from an intensive effort to prevent hypoglycemic events and help patients recognize and appropriately manage hypoglycemia events when they occur,” the authors write.

For the pilot initiative, three tools will be tested for effectiveness.

“One tool will see if patients are having low blood sugar, a second will see how confident patients are in managing their low blood sugars, and a third is a series of educational interventions that clinicians will be able to use with their patients in a shared decision-making model,” said Dr. Lash. “There will be information to read and take home but also materials that clinicians will share with patients to help them make decisions that will help them reduce their chance of hypoglycemia.”

For example, while lower A1c targets have helped reduce the number of diabetes complications, they also have increased the risk of hypoglycemia. A clinician may suggest a patient stop or lower their medication and permitting A1C to rise a little bit, to keep a patient from having low blood sugars. Patient and doctor can employ the shared educational tools, infographics and other information to make the decision. The study is designed to see how it goes on the first visit, then three and six months later.

An Important Goal

“The overriding goal is to reduce the number of patients at risk who are on insulin or sulfonylureas and to decrease the frequency and severity of hypoglycemia as an adverse drug event among type 2 diabetes patients,” said Jeff Boord, MD, MPH, an endocrinologist at Parkview Health in Ft. Wayne, Indiana.

“There are multiple national clinical practice guidelines for diabetes that are used to guide patients in the US and other countries, with a target of an A1C of less than 7%,” said Dr. Boord. “But the guidelines also emphasize that individualized targets should be developed based on individual patient practices to help prevent hypoglycemic episodes.”

“Patients who have an A1C of less than 7% that has been achieved with an agent that does not have a high risk of hypoglycemia—such as GLP1 agonists, metformin, SGL2 inhibitors, or DDP4 inhibitors—may lower their risk of hypoglycemia,” said Dr. Boord.

The pilot project will work on “identifying patients who are at a high risk in a timely manner, supporting appropriate clinical interventions that can be administered in primary care providers’ offices and clinics and decreasing the frequency and severity of hypoglycemic episodes,” said Dr. Boord.

“We’re going to be measuring outcomes in terms of the number of hypoglycemic events as well as self-efficacy of patients when it comes to managing hypoglycemia,” said Dr. Boord.

The initiative will also involve a broad set of stakeholders affected by the problem.

“These will include primary care providers, family members and patients who suffer from the events and suffer severe outcomes, endocrinologists who work with high-risk patients and the public at large since adverse events from hypoglycemia affect health care costs. Pharma is also engaged because it impacts the safety and efficacy of medications,” he said.

Hypoglycemia, Dr. Boord noted, can have a severe negative impact on everyday life.

“It can affect the quality of life, social life, work productivity, and ability to drive safely,” he said. “And in some cases, the more it affects your quality of life, the more likely you will be less adherent to treatment.”

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