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High burden of insulin-related hypoglycemia

Publish date: March 10, 2014
Author(s):
Mary Ann Moon

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Drug industry fuels overuse of insulin

Severe insulin-related hypoglycemia is not just "remarkably common," it also differs from most other causes of emergency department visits in that it is almost always iatrogenic, said Dr. Sei J. Lee.

And as noted by Dr. Geller and his associates, the 50% increase in insulin use during the past decade is fueling this epidemic of hypoglycemia. That, in turn, can be attributed to the drug industry’s "all-too-effective efforts ... to encourage patients and providers to intensify glycemic treatment." Pharmaceutical companies have "shaped the current widespread belief in tight glycemic control that has led to aggressive prescribing" of insulin, he said.

"We should not accept the current rates of hypoglycemia as inevitable" or as an acceptable price to pay for treatment, Dr. Lee said. "Rather, we should begin using a multipronged approach to decrease the overuse of insulin and minimize the risk of hypoglycemia."

Dr. Lee is with the division of geriatrics at the University of California and the Veterans Affairs Medical Center, both in San Francisco. He reported no relevant financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Geller’s report (JAMA Intern. Med. 2014 March 10 [doi:10.1001/jamainternmed.2013.13307]).


 

FROM JAMA INTERNAL MEDICINE

Severe hypoglycemia related to overly "tight" insulin control for type 2 diabetes prompts nearly 100,000 emergency department visits and 30,000 hospitalizations each year and is particularly common among older patients, according to a report published online March 10 in JAMA Internal Medicine.

In an analysis of data from a nationally representative sample of hospitals in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project, researchers estimated that 97,648 ED visits occurred annually during a 5-year period among adults with type 2 diabetes who presented with hypoglycemia-related shock, loss of consciousness, seizure, injury or fall, or altered mental status. Most cases involved blood glucose levels of 50 mg/dL or less, said Dr. Andrew I. Geller of the division of healthcare quality promotion at the Centers for Disease Control and Prevention, Atlanta, and his associates.

The case rate was 34.9 per 1,000 insulin-treated patients among those aged 80 years and older. In comparison, the rate was only 13.7 per 1,000 among those aged 45-64 years. Older patients were more than twice as likely as younger ones to require an ED visit and nearly five times as likely to require hospitalization, Dr. Geller and his associates said (JAMA Intern. Med. 2014 March 10 [doi:10.1001/jamainternmed.2014.136]).

The most common precipitating factor was "meal-related misadventure" – failing to eat shortly after taking rapid-acting insulin or failing to adjust the insulin regimen to account for a missed meal or a very small meal. Hypoglycemia also was frequently preceded by the patient taking the wrong dose of insulin or the wrong insulin product, usually taking rapid-acting insulin instead of long-acting insulin.

"These data probably underestimate the total burden of hypoglycemic events because hypoglycemia, although a frequent cause of [emergency medical services] calls, is most often cared for outside the ED setting. Patients who have hypoglycemia unawareness and whose episodes do not result in EMS or ED care [were] not counted, nor [were] those who died en route to the ED," they added.

No financial conflicts of interest were reported.

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