Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Quality, Safety & Value

Menu
Menu

Quick Links

Veterans Crisis Line Badge
My healthevet badge
EBenefits Badge
 

For Clinicians

Hypoglycemia Risk:  Intensive management of diabetes increases the risk of hypoglycemia 1, 2. Elderly patients are at high risk for hypoglycemia, and more likely to require assistance or hospitalization as a result.  Cognitive impairment increases the risk of hypoglycemia 3. Insulins (13.9%) and oral hypoglycemics (10.7%) were among the top 4 drug classes implicated in emergency department visits and hospitalizations 4. 

Choosing Wisely: American Geriatrics Society Recommendation: “Avoid using medications to achieve A1C < 7.5% in most adults age 65 and older; moderate control is generally better.” 5 

Overtreatment of Elderly Veterans appears to be common3:

·        38% of Veterans > 65 years of age had A1C < 7

·        7.5% of Veterans > 65 years had hypoglycemia documented in past 2 years 

·        14% of patients with dementia had hypoglycemia documented in past 2 years 

Patients at Greatest Risk for Hypoglycemia:

·        A1C < 6.0 (~4x risk); < 6.5 (2.25x risk) or < 7.0 (~2x risk)6

·        Treatment with insulin (5x risk) or a sulfonylurea (2x risk) (glyburide, glipizide, etc.)

·        Age > 75

·        Cognitive impairment 

Recommendations: Review patients at greatest risk for hypoglycemia, as outlined above

·        Identify individualized A1C goal  based on patient preferences, complications, and co-morbidities

·        Reduce or eliminate unwarranted medications, focusing on insulins or sulfonylureas first as they pose the greatest risk for hypoglycemia

·        In general, prefer not using newer diabetes agents with goal of relaxing the A1c target based on safety and evidence- lowering doses of existing medications preferred 

References

·        Patel A, McMahon S, Chalmers J et al:  Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358:2560-72.

·        Bonds DE, Miller ME, Bergenstal RM, et al: The association between symptomatic, severe hypoglycemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. BMJ 2010; 340:b3409.

·        Feil DG, Rajan M, Soroka O, et al: Risk of hypoglycemia in older Veterans with dementia and cognitive impairment: Implications for practice and policy. J Am Geriatr Soc 2011;59(12):2263-72.

·        Budnitz DS, Lovegrove MC, Shehab N, Richard CL: Emergency hospitalizations for adverse drug events in older Americans.  N Engl J Med 2011: 365: 2002-12.

·        http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/

·        Tseng CL,Soroka O, Maney M, et al: Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med 2014: 174(2):259-68.