Clinical Edge

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Severe Hypoglycemia in Adults with Diabetes

Diabetes Care; 2017 Dec; Lee, Lee, Huang, et al

In adults with a mean age of 64 years, diabetes, poor glycemic control, glycemic variability, kidney damage, and measures of cognitive and functional impairments were strongly associated with increased risk of sever hypoglycemia. 1,206 adults (mean age 64 years, 32% black, 54% female) from the Atherosclerosis Risk in Communities (ARIC) study with diagnosed diabetes from 1996-1998 were included with severe hypoglycemic events identified through 2013. Researchers found:

  • Important risk factors for severe hypoglycemia included age (per 5 years: hazard ratio [HR], 1.24), black race (HR, 1.39), diabetes medications (insulin vs no medications: HR, 3.00), glycemic control, macroalbuminuria, and poor cognitive function.
  • In an analysis of nontraditional risk factors, low 1,5-anhydroglucitol, difficulty with activities of daily living, Medicaid insurance, and antidepressant use were positively associated with severe hypoglycemia.

Citation:

Lee AK, Lee CJ, Huang ES, Sharrett AR, Coresh J, Selvin E. Risk factors for severe hypoglycemia in black and white adults with diabetes: The Atherosclerosis Risk in Communities (ARIC) study. Diabetes Care. 2017;40(12):1661-1667. doi:10.2337/dc17-0819.

Commentary:

Hypoglycemia is important to avoid both because of its acute consequences that can include loss of consciousness and falls, and because of potential long-term consequences. We have always known about the short-term effects of hypoglycemia, but in the last few years new evidence has emerged showing that hypoglycemia is associated with an increase in cardiovascular outcomes over the subsequent 3 years.1,2 It is not surprising that increasing age and poor cognitive function is associated with increasing rates of hypoglycemia. The surprising result in this study is that good glycemic control was not associated with hypoglycemia and that in fact, the opposite was true. Patients with moderate glycemic control had more hypoglycemia than those with good control (HR, 1.78), and patients with poor control had more episodes of hypoglycemia than those with good control (HR, 2.62). The take home point here is that all patients, not just those with tight control, are at risk for hypoglycemia. —Neil Skolnik, MD

  1. Zoungas S, Patel A, Chalmers J, et al; ADVANCE Collaborative Group. Severe hypoglycemia and risks of vascular events and death. N Engl J Med. 2010;363:1410–1418. doi:10.1056/NEJMoa1003795.
  2. Bonds DE, Miller ME, Bergenstal RM, et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. BMJ. 2010;340:b4909.

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