Older age associated with increased ED visits for insulin-related hypoglycemia

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1.  Insulin-related hypoglycemia and errors (IHEs) lead to a large number of emergency department (ED) visits and hospitalizations, especially among patients who are 80 and older. 

2. Among all age groups examined, use of insulin alone was associated with a multifold increase in IHEs when compared to patients using a combination of insulin and oral anti-diabetic agents. 

Evidence Rating Level: 2 (Good)           

Study Rundown:  Insulin has been the established treatment of choice for Type I diabetics.  As more aggressive glycemic targets are proposed, an increasing number of Type II diabetics are also being treated with insulin.  Aggressive glycemic controls have become controversial since the ACCORD trial demonstrated increased mortality. This study found that patients who are older than 80 years of age and treated with insulin were twice as likely to end up in the emergency department (ED) for evaluation of IHEs as compared to those aged 65-79.  They also found that across all age groups, patients using only insulin were several times more likely to have an IHE as compared to patients on insulin and an oral agent.  The strengths of the study include the large sample size examined to generate the national estimates.  In addition, the authors broke down the results according to several age groups and collected extensive information on the types of IHEs experienced by the patients and the combinations of medications they were on.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Effects of Intensive Glucose Lowering in Type 2 Diabetes (ACCORD trial)

In-Depth: In this public health surveillance study, the authors used data from the National Electronic Injury Surveillance System – Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project to estimate the annual numbers of ED visits and hospitalizations for insulin-related hypoglycemia and errors (IHEs) among patients with diabetes mellitus treated with insulin between 2007 and 2011.  They also estimated the number of patients in the US with diabetes using insulin or oral anti-diabetic agents from the National Health Interview Survey (NHIS).  Based on 8100 NEISS-CADES surveillance cases, they estimated that 97,648 (95% CI, 64,410-130,887) ED visits for IHEs occurred annually between 2007 and 2011.  95.4% of ED visits for IHEs were due to hypoglycemia.  Patients who were 80 or older had the highest estimated rate of ED visits for IHEs (34.9 per 1000 insulin-treated patients; 95%CI, 20.5-49.3).  Patients in this age group also were five times as likely to be hospitalized for IHEs as those between the ages of 45-64 (RR, 2.5; 95% CI, 1.5-4.3).  In patients 18 years or older, those on insulin only were 5 times as likely to have ED visits for IHEs as those on insulin and at least 1 oral anti-diabetic agent (RR, 5.3; 95% CI, 3.2-8.8).

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