Experts Call for Health System Action to Reduce Hypoglycemia Risk in Older Adults With Diabetes

Hypoglycemia—a dangerous condition for individuals living with diabetes—is receiving insufficient attention, according to a panel of experts at the American Diabetes Association 83rd Scientific Sessions.

Specifically, the panelists highlighted the underappreciated risks of low blood glucose and emphasized the need for both patient-level and system-level changes to address the issue effectively.

A key concern raised during the session was the lack of safety targets for hypoglycemia despite treatment guidelines focusing on hemoglobin A_1C (HbA_1C) targets. This oversight, combined with the failure of clinicians to asl about hypoglycemia during patient visits as well as patients' reluctance to disclose hypoglycemic events—largely due to concerns over consequences like losing driving privileges—contributes to the underrecognition of this issue.

With a quarter of older Americans having diabetes and about 68% taking at least 1 hypoglycemia-inducing agent such as insulin, sulfonylureas, or a combination, more attention and education to prevent hypoglycemia is vital.

“Not surprisingly, the leading causes of hypoglycemia in older individuals are insufficient nutrition and accidentally taking the wrong dose or type of insulin,” said Alexandria Ratzki-Leewing, PhD, director of the Hypoglycemia Program at Schulich School of Medicine & Dentistry, Western University. “The direct costs of hospitalization for severe hypoglycemia in the US alone is more than $1.8 billion.”

Drawing on a combination of data from clinical trials, health records, patient self-reporting, and continuous glucose monitoring (CGM), it was revealed in the session that older individuals with diabetes experience an average of 1.3 hypoglycemic events each day. Intensive glycemic control using insulin and/or secretagogues like sulfonylureas also elevates the risk of severe hypoglycemia by 150% to 300% compared with standard control, with risk increasing with age, according to Ratzki-Leewing. She added that a single hypoglycemic episode was shown to elevate the risk of other adverse events for a decade or longer.

The panelists also underscored the potential for therapeutic and technological interventions to prevent hypoglycemia in older adults with diabetes. With how commonly insulin and sulfonylureas are used among this population, adjusting regimens based on robust evidence can easily and significantly decrease the risk of hypoglycemia.

Anna Kahkoska, MD, PhD, assistant professor of nutrition at the University of North Carolina, said there is a clear pattern of overtreatment with insulin and sulfonylureas.

“Overtreatment is more common in people who are older and more medically complex, specifically those with heart failure, chronic kidney disease, or coronary artery disease,” Kahkoska said. “Deintensification of sulfonylureas and insulins is not common, even in the setting of acute complications.”

CGM’s potential to reduce severe hypoglycemia risk was also discussed, but the adoption of CGM technology is notably lower among older adults compared with younger age groups, necessitating improved support and education to increase uptake and sustained use.

“We need improved support for older adults, their care partner, and providers to improve CGM uptake and sustained use,” Kahkoska noted. “We need to think of CGM as a safety tool for both patients and providers.”

Kasia Lipska, MD, MHS, BS, associate professor of endocrinology at Yale School of Medicine, emphasized the need for systemic changes, highlighting how the profit-oriented health care approach has led to high patient volume, shorter appointment times, and inadequate diabetes support, overall hindering effective care.

The growing focus on quality measures in diabetes care was also criticized for rewarding providers and patients for achieving HbA_1C targets without corresponding safety targets to prevent hypoglycemia. Cost is another barrier for patients and payers, as it affects the adoption of alternative medications and technologies like CGM that are aimed at reducing hypoglycemia risk.

“We do not do a good job of individualizing diabetes care,” Lipska said. “Barely half of people with severe hypoglycemia discuss the event with their provider, and older adults show tighter glycemic control than younger adults, the opposite of what we want. We know that higher out-of-pocket costs decrease the likelihood of use of appropriate medications and technologies.”

Of the systems that have launched pilot programs targeting hypoglycemia, many are seeing improvements, but more system-level interventions are needed to reduce hypoglycemia risk.

“Few health care systems have adopted any interventions to reduce, or even track, hypoglycemia,” Lipska said. “But we are seeing that change is possible.”

Reference

Session examines how to reduce hypoglycemia at patient and system levels.American Diabetes Association. August 8, 2023. Accessed August 9, 2023. https://www.adameetingnews.org/live-updates/session-coverage/session-examines-how-to-reduce-hypoglycemia-at-patient-and-system-levels/