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
· 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.
· 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.