There is an urgent need to address key deficiencies in evidence supporting strategies to reduce the incidence of hypoglycemia in patients with type 2 diabetes, say the authors of an “environmental scan.”
The policy analysis was published online March 5 in the Journal of Clinical Endocrinology & Metabolism, the official journal of the Endocrine Society.
“Hypoglycemia is well recognized as a threat among people with type 1 diabetes and their healthcare providers, [but] the danger it poses to people with type 2 diabetes is underappreciated,” lead author Robert Lash, MD, chief, professional & clinical affairs officer at the Endocrine Society, said in a statement.
“The current landscape clearly demonstrates the need to address hypoglycemia as a routine part of clinical care for individuals with type 2 diabetes [as well],” he added.
Tools for Reduction and Management of Hypoglycemia Do Exist
Lash, who is also from Michigan Medicine, Ann Arbor, and colleagues from Avalere Health, Washington, DC, analyzed 31 articles from the literature and searched the internet for relevant websites.
This so-called “environmental scan” included assessments on clinical guidance documents, quality measures and their use in value-based purchasing programs, clinical tools related to both hypoglycemia and type 2 diabetes, and quality improvement initiations.
“Not surprisingly, our findings suggest that interventions to reduce hypoglycemia should focus on helping clinicians identify high-risk patients who would most benefit from an intensive effort to prevent hypoglycemic events and help patients recognize and appropriately manage hypoglycemic events when they occur,” the policy authors write.
Identifying patients most at risk for hypoglycemia should start with age, as patients with type 2 diabetes 65 years of age and older are the most susceptible.
That said, a meta-analysis (PLoS One. 2015;10:e0126427) indicates that patients with type 2 diabetes taking insulin on average experience 23 mild or moderate hypoglycemic episodes and 1 severe episode each year, so type of glucose-lowering medication must also be considered as part of the equation.
Clearly, hypoglycemic episodes with such frequency can compromise quality of life, say Lash and colleagues.
Practitioners also need to better identify risk factors for hypoglycemic events.
As the authors note, none of the 34 measures related to HbA1c control identified in the review addressed the reduction or management of hypoglycemia in an out-patient setting, despite the fact that several of these measures do exist.
For example, the Centers for Medicare & Medicaid Services (CMS) Measures under Consideration List includes 2 measures regarding HbA1c control for patients with an HbA1c < 8%.
The National Action Plan for Adverse Drug Event Prevention also includes 6 electronic clinical quality measures for practitioners that could help prevent hypoglycemia. If such proposed measures were adopted in quality programs, the authors predict that many of the existing gaps in evidence regarding prevention and control of hypoglycemia could be addressed.
There is also a dearth of resources aimed at physicians to help them identify and manage patients with type 2 diabetes at high risk for hypoglycemia, Lash and colleagues note.
Two risk assessment tools do exist, although neither is widely use: a hypoglycemia risk stratification tool (JAMA Intern Med. 2017;177:1461-1470), which was developed by Kaiser Permanente, as reported by Medscape Medical News, and a hypoglycemia risk reduction clinical reminder (Diabetes Spectr. 2017;30:211-216).
Initiatives and Pilot Programs
“Beyond risk assessment tools, our environmental scan identified a variety of educational resources to support clinicians and patients in reducing patients’ risk for hypoglycemia,” the researchers observe.
Some of these resources are aimed at patients in an effort to improve self-managements skills so they can better recognize and handle hypoglycemia events.
In their own initiative, the Endocrine Society is planning to develop a toolkit of resources for physicians and patients to improve care for those at risk for hypoglycemia.
And countrywide initiatives in the United States, such as the National Action Plan, are highlighting concerns about the risk of hypoglycemia associated with insulin and sulfonylureas.
“Translating the national action plan into action, the US Food and Drug Administration’s ongoing Safe Use Initiative seeks to reduce preventable harm by identifying specific, preventable medication risks,” the authors note.
These risks will be communicated with stakeholders committed to safe medication use, including the Endocrine Society, they add.
Another promising national initiative was recently piloted by the Veteran’s Administration whereby electronic health records were sent to primary care physicians (PCPs) to help them identify patients treated to HbA1c levels that might do more harm than good.
“A key goal of the project was to have PCPs engage patients in conversations about their HbA1c goals and discuss potential changes to their treatment plans,” the authors observe.
The project was an apparent success, as hypoglycemic episodes in the target group dropped by 18% about 6 months after initiating the intervention and by 22% at 18 months (JAMA Intern Med. 2017;177:1461-1470).
And the Endocrine Society is moving forward with a pilot project designed to assess a number of interventions to reduce hypoglycemia risk in high-risk patients with type 2 diabetes.
As the authors explain, interventions will be targeted to patients over the age of 65 who require insulin or a sulfonylurea for glycemic control, paying special attention to those who have an HbA1c < 7% and comorbidities suggesting a higher HbA1c level might be considered.
“We believe that a combination of robust clinical decision support tools along with the efficient use of shared decision-making techniques will help identify effective interventions,” the review authors note.
“[And] we believe this initiative will help us develop strategies to avoid hypoglycemic events while building support for the inclusion of hypoglycemia prevention in value-based diabetes care models,” they conclude.
The review was supported by Abbot Diabetes Care. The authors have reported no relevant financial relationships.
J Clin Endocrinol Metab. Published online March 5, 2018. Full text
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