Risk of Subsequent Hypoglycemia is Low When Diabetes Treatment is Intensified

Clinicians should not be afraid of intensifying treatment in diabetic patients with inadequately controlled glucose levels because the subsequent risk of developing hypoglycemia is quite low, a new study has shown. 

Intensifying therapy did not increase the risk of hypoglycemia, even among those with hemoglobin A1c (HbA1c) levels close to goal, say investigators.

"The problem is that patients aren't very well controlled," lead investigator Dr David Ziemer (Emory University School of Medicine, Atlanta, GA) stated. "In this study, their average HbA1c was 8.0%, but these are all people who have been in the clinic for six months or more, so they should be better controlled. One of the big fears, for both providers and patients, is hypoglycemia. Because they tend to be afraid of hypoglycemia, they tend to be hesitant about changing medications, or the frequency with which they change the medications."

Ziemer said that even among patients with HbA1c levels <7.5%, increasing the medication dose or switching medications did not increase the risk of subsequent hypoglycemia.

Ziemer said that glycemic control, despite its proven benefits, remains elusive for many diabetic patients. Clinical inertia, the failure to intensify treatment in the face of inadequate control, is problematic for providers as well as patients; both are often reluctant to intensify treatment because of the fear of subsequent hypoglycemia, an uncomfortable condition characterized by hunger, nervousness, shakiness, dizziness, confusion, or anxiousness.

Of the 2413 patients who reported or were coded for any hypoglycemia, a little more than half had just one event. Overall, 6.7% of patients reported three or more hypoglycemic events and accounted for 50% of the total hypoglycemia episodes. "There is a small number of people who account for most of the hypoglycemia," said Ziemer. "There is a small high-risk population and it's probably important for us to be able to identify them because these are the patients we need to be careful with."

Looking at provider data individually, Ziemer said that in the clinic, when presented with a patient who had high blood glucose levels, approximately 60% to 73% of doctors intensified treatment, and this did not increase the risk of developing subsequent hypoglycemia. Multivariate analysis also showed that intensifying therapy did not increase the risk of developing hypoglycemia, in the total population or in patients with HbA1c levels <7.5%.

"There is a small group of people who are at higher risk," said Ziemer. "It's not something doctors should not worry about, but the risk is actually quite low. This risk, though, also needs to be put in perspective with the beneficial long-term outcomes of getting patients controlled."

Patients treated with insulin had the highest risk of developing hypoglycemia. However, in an analysis looking only at patients treated with insulin, Ziemer said, intensifying therapy did not increase their risk of developing hypoglycemia.

Asked why some doctors won't intensify therapy despite the benefits, Ziemer said nobody wants to be responsible for sending a patient to the emergency room or for that patient to be involved in a car accident because of hypoglycemia. However, with the study showing only a small risk, one that is largely relegated to a group of high-risk patients, doctors should intensify treatment by upping the dose, adding another drug therapy, or simply getting patients restarted on their medications. In terms of knowing who is at high risk, patients who have multiple hypoglycemic events and those with large variability in the blood glucose levels are those most at-risk of subsequent hypoglycemic events with intensified therapy, said Ziemer. 

Source: Diabetes In Control: Ziemer DC, Barnes CS, Tsui CW, et al. Hypoglycemia is not associated with intensification of diabetes therapy. American Diabetes Association 2007 Scientific Sessions; June 24, 2007; Chicago, IL. Poster 1222.