Hypoglycemia: An Unrecognized Complication in Diabetes

Mark Warren, MD: When looking at the rates of hypoglycemia, if you look at claims data, you won’t find an accurate reporting because, generally, in practice we don’t code for hypoglycemia. And the only time you really code for it is if they come to the hospital with severe hypoglycemia, for example. So, I think the rates of hypoglycemia, if you look at claims data, are not going to get you an accurate view of what’s going on. We know from continuous glucose monitoring that even patients with type 2 diabetes, 80% of them, will have hypoglycemia, usually unexpected and unknown hypoglycemia during 5 days of continuous glucose monitoring. So, it is a significant problem that I don’t think we capture very well in looking at ICD (Internal Classification of Diseases) codes, the coding in the hospital, as well as in the physician practice.

The coding for hypoglycemia is mostly from hospital-based coding. If someone comes to the emergency department with severe hypoglycemia, they’re going to be coded for that. In the practice, we almost never code for hypoglycemia unless they’re coming in comatose or requiring the assistance of someone else in the waiting room. But we always ask about it—we simply don’t code for it. We just call it uncontrolled diabetes. So, if you’re looking at their claims data and the ICD coding, I don’t think you’re going to get an accurate reporting from the outpatient. And that does become a concern, an issue, when we look at how these new insulins are going to help us if someone says, “Well, there’s not that much hypoglycemia out there.” Well, I think you have to look at where your data are coming from. And, if you look at continuous glucose monitoring results, you’ll see that it’s anywhere from 50% to 80% of patients who have unexplained or unsuspected hypoglycemia. So, it is a problem. I don’t think we’re aware of just how much of a problem it is.

Nocturnal hypoglycemia is a big problem for our patients. What happens is that we get 1 episode of severe, or even mild to moderate, nocturnal hypoglycemia, and that complete changes what the patients do. They start decreasing their doses of insulin. They start eating preemptively at bedtime to prevent nocturnal hypoglycemia. So, they’re really concerned about it and they do whatever it takes to prevent it. We always ask about it. We ask, “Do you have any night sweats? Do you wake up with unusual dreams? Have you checked your sugar at night when you get up to go to the restroom?” We ask about it, and we often find that it is a concern of the patients. I always find that if they’ve ever had an episode, they will do everything in their power to prevent a second episode.